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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD Wyd� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 's _ I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Ar DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M —O _ 1 I B. MANUFACTURED BY: lj C. DATE INSTALLED(MOADAYNEAR)-- 1. ( ( L,r D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. AR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION A r�dpl MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULGAB .JY❑ 2 PETROLEUM ❑ 80 EMPTY �l PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S,AND C,AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER E] 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM F72 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT E:] 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 1< 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED �❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ly I, 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLES WITH 100% METHANOL? YESX NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION F75 CATHODIC PROTECTION ❑ 9/ NONE SPILL CONTAINME INSTALLED(YEAR) OVER FI PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DRQP TUBE YES NO_ RIKER PLATE YES NO_ DISPENSER CONTAINMEN YES NO IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND O UIFUNDERGROUND.BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B, CONSTRUCTION A U 1 SINGLE WALL A ®2 DOUBLE WALL A U 3 LINED TRENCH A U 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)A04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U ? STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECNNMCII UNE LEAK 2 UNE TNiNnh55 3 CONTINUWG INiER5m1AL ❑4 ELECTRONIC LINE ❑5 AIITGM4TIL POMP ❑ 99 OTHER D. LEAK DETECTION ❑ O naw ❑ IEanw MOMTORNG LEAX DETECTOR SNUf90mI V.TANK LEAK DETECTION E-11 VISUAL CHECK ❑ 2 GAK RECONCILIATIONORY ❑ 3 MONITORING VADOZE )K714 GAUG NGAUTOMATIC TANK ❑5 MONITORING�R ❑ 6 TESTINGTANK ❑ T MON TORNG INTERSTITIAL ❑ B SIR ❑ 9 TANK WEEKLY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOT T OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRIMED d 61GNANRE) A/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It FACILITM>t TANKM STATE LD:# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE MUST BE COMPLETED FOR INSTAL THIS FORM MUSTSHOULD BE ACCOMPANIED BY AIP OT PiI�ILEFORM THIS FORM WITH THE LOCAL AGE UNLESS A CURRENT FORM CY IMPLEMENTING THEA HAS BEEN FILED. �GROUND STORAGE TANK RELATIONS B.THIS FORM FORM B (6-95)