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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ~o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� =� I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: DC7 G• LG.O/ ✓ . I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# v B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) �• D. TANK CAPACITY IN GALLONS: /D II.TANK CONTENTS IFA.IISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. C_ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS �,# b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ l METHANOL 2 PETROLEUM ❑ 90 EMPTY �1 PRODUCT ❑ 1c MIDGRADE UNLEADED nT�-- ' 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN 2 WASTE ❑ 2 LEADED u 99 OTHER(DESCRIBE IN REND.BELOWI D. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. 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 UNER ❑ 5 INTERNAL BLADDER SYSTEMIyI 95 UNKNOWN SYSTEM F72 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT F-199 OTHER T' B. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 4 PHENOLIC LINING 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY UNING C.INTERIOR ❑ ❑ LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ N OTHER E.SPILL AND OVERFILL,EIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH q 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 /COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION O 1 WCN00'R I LINE LEN( O 2 WE MWNESS O 3 CQYTINUOUS IWERSTmAL ❑4 ELECiRIXaC UNE O 5 AVio"TIC"JW O 99 OTHER OETEClOR TESRNp MONTM4 LEN(L1E1Ecrgi SNUTWWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILATIONANUAL INVENTORY ❑ 3 MONIITORING OZE ❑ 4 AUTOMATGAUGNGIC TANK [:] 5 MONTORINGTER ❑ 6 TANNUAL ESTINGTANK ❑ T MOTI CONITORINGNNUOUS INTERSTITIAL EJ B SIR ❑ 9 TANEK GAU INGAL ❑10 TOSNTHLY TING TANK ,A? 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS IN 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 (PRINTM A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# b TANK# � STATE LD:# LEI p p D 0 � £ I a PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE 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 SHOULD BE ACCOMPANIED BY A PLOT PLA" 'LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE L' 1GROUND STORAGE TANK REGULATIONS FORM B (6-95) ) w Iadl