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0 • o.cea STATE OF CALIFORNIA �4a °Oi STATE WATER RESOURCES CONTROL BOARD 3��,. ..o 0 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ro DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Y� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/9EAR) D. TANK CAPACITY IN GALLONS: 170 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ,-1 1 MOTOR VEHICLE FUEL 4 OIL B. ��yyy C. 1e REGULAR UNLEADED 3 DIESEL E] 6 AVIATION GAS TyL 2 PETROLEUMBD EMPTY 1 PRODUCT O iG PREMIUM UNLEADED ❑ SFU ❑ METHANOL 1c MIOGRADE UNLEADED 5 JET EL 8 M85 ❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Xl SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 'F5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED IIIA❑] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING Imp 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHECTON ODICPROT91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENT( N OUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 61 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A 'U 33 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A ,� // STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECXANICAL LME IFA(( 2 UNE POWNE55 3 C INUWS IWERSWWAL 4 ELEC IC UNE 5 AUTOMAWC PUW ❑ OETECfOR ❑ T NG ❑ MOMTORING CEAK DEME N SHViDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY E] 3 VAOZEMONANNUALTANK IITORING ❑ 4 GAUGINGAUTOMAT TANK ❑ 5 MONITORINGGROUND ❑ 6 TESTING ❑ 7 MON INUOU INTERSTITIAL ❑ 8 SIR 9 WENKGAUGINGAL [:]10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(all) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �-(�FACILITY#T TANK# STATE I.D.# 1 1 _ 1 1 1 = Q PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PLWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B (6.95) ��il