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• STATE OF CALIFORNIA • 'c�c' 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :r 1 - COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF I❑ NFORMATION 7-1J PERMANENTLY CL ITE 1 MARK ONLY ❑ ONE REM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 1:1B TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: //7- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 70. MANUFACTURED BY: A. OWNER'S TANK i.D.Y C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: 14 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. Ltfto REGUUUI UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS A. 1 MOTOR VEHICLE FUEL ❑ d OIL 8. O ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL ❑ 80 EMPTY PRODUCT ❑ 2 PETROLEUM ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N REM D.BELOW? C.A S.It: D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D ANO E I UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 6 SINGLE WALL IN A VAULT ❑ 99 OTHER SYSTEM 2 SINGLE WALL I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANKg POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR s GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ EX ❑ DATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. TERIOR 1 POLYETHYLENE WRAP ❑ CORROSION gt NONE El 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,6IC. DROP TUBE YES__ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2- DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U ? STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION pU 95 UNKNOWN A U 99 OTHER 1 4ECHNMAL UNE LEA?( 2 EES IIGInME55 ❑3 uONTORINO E�Imu ❑4 IFAII OETECfOH ❑5 A OS wMP ❑ 99 OT ER 0. LEAK DETECTION ❑ oErEtroR ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 MONOITORING 4 AUTOMATIGAUGINGC TANK ❑ 5 MONITORINGGROUND 6 TESTINGANNUALTANK RECONCILIATION ? CONTINUOUS ONTINU U INTERSTITIAL ❑ 6 gip ❑ 9 WE K LY MANUAL ❑10 TESTING TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH V0S NO ❑ 1.ESTIMATED DATE LAST USED(MO/OAYIYR) 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 NAATE ME (PRINTED a 51GNATURIR LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITYFACILITY x� TANK# STATE 04 2 �/�21LJ�� 5 1 �V`V PERMIT NUMBER PERMIT APPROVED BVIDATE PERMIT EXPIRATION DATE y yFl IN THIS FORM MUSTSHOULD ACCO PANTED BY A PERMIT BY A AP U OFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING��EMbbabENTING THRM A HAS BEEN FILED. FOF '-RM GROUND STORAGE C MUST BE COMPLETED TANKR1REGULA/TIONSNgTHIS FORM FORM B (6-95)