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• i a c STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARD ?ei� —,e 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > . ,� 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONqTE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN /�� p / B. MANUFACTURED BY: A OWNERS TANK I.D.# (P:J C. DATE INSTALLED(MO/OAYNEAR) (, D. TANK CAPACITY IN GALLONS: 12_4 C] b II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. to REGUL4R UNLEADED ❑ 3 DIESEL El AVIATION GAS A � 1 MOTOR VEHICLE FUEL ❑ d OIL B. O lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY xf 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN A. TYPE OF ❑ ❑ SYSTEM ❑ 2 SINGLE WALL d SINGLE WALL IN A VAULT 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F--] 5 CONCRETE F-16 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP (PNmory Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F] 4 PHENODC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING ca UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YESX NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ SPILL CONTAINMEN I STALLED(NEAR) OVERFI LPREVENTION EQUIPMENT INSTALLED(NEAR) E SPILL AND OVERFILL,ete. DROP TUBE YES NO_ S R ER PLATE VES NO_ DIBPENBER CONTAINMENT YES NO_ IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND OFOFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION AO2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI 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 1 MECNAl1IGl UNE LERIL 2 UNE TIGHINEW �L.g CgNINNOUB INIERST9LLL d ELECTRONIC UNE ❑5 AVfONATIC WMP ❑ 99 OTHER D. LEAK DETECTION ❑ BETECTOR ❑ TESTING �L M Tww TE.ix oE1EcroN sHUToowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALRECONCILIATION ORY ❑ 3 MAODNIITORING GAUGING IC TANK F-15 MONTORINGOUND TER ❑6 ANNUALTESTING ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TAENK GAUGINGAL ❑10 TESTING MONITHLTANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED LMC/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:] "0 El NCEREMAINING 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 (PRINTED B SIGNATURE)—JRl l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# mF= 161DI= FM01)1611C01 PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE 3 MUST BE MPLETED THIS FORM MUSTSHOULD BE ACCOMPANIED BY AI PLOT PIWLE THIS F-FORM ORM WITH THE UNLESS A CURRENT OCAL AGENCY IMPLEMENTINGTHE�GROUND STORAGE E TANKRREGULATIONSNB.THIS FORM FORMS (6-95)