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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B sn _ 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 7 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ��❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT El 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE KI 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q Aj �G.wti 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN � e A OWNER'S TANK I.D.# B. MANUFACTURED BY: /� C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A O i MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL ❑ 1e MIDGRADE UNLEADED E] 5 JET FUEL E:] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 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.p 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM }12 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER x B. TANK L<1 BARE STEEL ❑ 2 STAINLESS STEEL E::] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL !❑_5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP )Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑/2 ALKYD LINING E] 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR E] 5 GLASS UNING IXI 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO-1-2�- D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION x N99 OTHER PROTECTION ❑ 5 CATHODIC PROTECnoN ❑ ❑ SPILL CONTAINMENT INSTALLED EAR) OVERFILL PREVENTION E UIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,810. DROPTUBE YES_ NO S RIKER PLATE YES_ NO DISPENSER CONTAINMENT VE NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A PSUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A / SINGLE WALL A U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A 0 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 7 LQENANIM UNE t 2 LINE Tw6TNEM 3 WNnNUW41N1FP.5TmAL 4 ELECmONIC NNE ❑5 AUfOMANC PVNP 98 OTHER D. LEAK DETECTION ❑ cE1EcTOR ❑ TESNNG ❑ MGMTORING ❑ LEAN OEIEOTOR SHUTOGWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADMONOZE ITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TESTING❑ 6 TESTINNUALGTANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR TANK GAUGING ❑10 TESTINGMONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(M AV R) 2.ESTIMATED QUANTITY OF� 3.WAS TANK FILLED WITH YES E:] NO SUBSTANCE REMAINING 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PLSFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IS U STORAGE TANK REGULATIONS FORM B (6-95) � _ � �/ �w � ��