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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD wo UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMfT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 75oo e G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN �L A OWNERS TANK I.D.R 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) � D. TANK CAPACITY IN GALLONS:S II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ I MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR UNLEED O 3 DIESEL ❑ 6 AVIATION GAS PETROLEUM �80 AD EMPTY ❑ i PRODUCT E] lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL n ❑ Ic MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 CHEMICAL PRODUCT ❑ 95 UNKNOWN % 2 WASTE ❑ 2 LEADED Ed 99 OTHER(DESCRIBE N ITEM D.BFLOM D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED n i If C.A S.R 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASnC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP TfiMM TYIII) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED �❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ED PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 17V 6 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION E:] 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PRoTEcnON 91 NONE SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENn EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BM. DROP TUBE YES_ NO RIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A91 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 �C m uKE uAll ❑2 UNE TK W ❑3 caxrwuaus NTER ❑4 B£CTAOMC UNE ❑5 AU nC MW 99 OTHER CETEam TEsraa HaxrC9m9 IENc r1ETECTCB 91U190WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 MODOZERING ❑ 4 GAUGINGIC TANK ❑5 MON TORINGGROUND �R ❑6 ANNUALTETING STINGTANK ❑ 7 MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 WEEKGA MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MODAYNPI 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUB STANCEREMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED O= SIGNATURE) ��II LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW oC I COUNTY p JURISDICTION p FACILITY N TANK p STATE I.D.# m ((a PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT KF5-i;l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM B (6-15)SHOULD BE ACCOMPANIED BY A PLOT`N. FILE �0/RS W��THE L G IMPLEMENTING L!// -�r ��{�T�OR G REGULATIONS lUu o �� r