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• • Wncti STATE OF CAUFORMA c i; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1d . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ ❑ T PERMANENTLY CLO ON SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVE 120 Rip 4 OBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK 1.D.Y C. DATE INSTALLED(MO/DAYMEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CO TENTS IFA-1 IS MARKED.COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS —1-5-71 ❑ ib PREMIUM UNLEADED d GASAHOL ❑ T METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ is MIOGRPDE UNLEADED ❑ 5 JET FUEL ❑ S M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBEIN REM O.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.Y III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ I UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK IFRP MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ B 100% METHANOL COMPATIBLE W (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 D UNING ❑ 3 EPDXY UNING ❑ 4 PHENOUC UNING C.INTERIOR LINING OR 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ COATING IS UNING MATERIAL COMPATIBLE WITH 100% METIANOLT YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 CO G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 95 UNKNOWN 99 OTHER ❑ 5 CATHODIC PROTEOTION 91 NONE PROTECTION OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) SPILL CONTAINMENT INSTALLED(YEAR) STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES NO E SPILL AND OVERFILL,BTC. PROP TUBE YES__ NO__ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER A. SYSTEM TYPE TRENCH A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A LL 1 SINGLE WAA U 2 DOUBLE WALL A U 3 UNED 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 S ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER 1 NECN4NIGIL UNE OF 2 NNE 11GHfNFSS ❑3 CAN WWS IMU45T ❑l B M M UNE ❑5 4UfON.KRC P11NP ❑ 99 OTHER D. LEAK DETECTION ❑ pEi am ❑ uoNTOPNG IFAK OEfECTOR sNuloown V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL)INVENT PY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND TER TESTINGTANK ❑ —1 99 OTHER 9 TANKMANUAL L ❑10 LY TANK ❑ 95 UNKNOWN T INTERSTITIAL ❑ B SIR TESTING MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE M-PUDE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ L ESTIMATED DATE LAST USED(MOIDAYIY I SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDOGE!IS TRUE AND CORRECT TANK OWNER'S NAME )PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �^--�FAC—IL�ITY k TANK# - � STATE I.D.# 7Z El z C ) PERMIT APPROVED SYMATE PERMIT EXPIRATION DATE f� Q PERMIT NUMBER ✓ U ESS A MPLETED OR IN TI THIS FORM MUST BE ACCOMED BY A PERMIT SHOULDBE PANIIEPANIEDBYAPLOTLIO�N-FILFOR FORM WITH THE LOCAL AGENCY IMPLEMENTING THCURRFORM A HAS BEEN FILED. FOPM MUSTAGROUND STORAGE ETANK REG A TONSNS THIS FOR FORME (6-95) 5-a5 f61 6 1X 1/�-