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a ..i STATE OF CALIFORNIA a +� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s, I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EVS CHANGE OF INFORMATION 7 PERMANENTLY C D DNSIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 hl I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.t 17 52A S. MANUFACTURED BY: C. DATE INSTALLED(MOADAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. n 1 MOTOR VEHICLE FUEL Q 4 OIL B. C. � y 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT Y1S1 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(AI)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.N: 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 I❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM {y�ell 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK L•J 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IDO% METHANOL COMPATIBLE W/FRP (PAmery Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ F]2 ALKYU LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR E:] 5 GLASS LINING x 6 UNLINED O 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE VES NO_ STRIKERPLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I 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 / 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 U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I Ia:cl.ORc uNE LEAK 2 UNE TIGHTNESS 3 ca NUOUS WER Mk 4 REC C UNE 5 AIR w=NMP ❑ OETECfOR ❑ TESTING MONITORING ❑ LEAK OEn MM ❑ EHUIWWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL VAE RECO CIUAnONORV E:] 3 MONITORING ❑ 4 GAUGING AUTOMATIC AUD MGIC TANK E] 5 MON ND WATER O 6 ANNUAGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 6 SIR ❑ 9 TANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO El 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 NAME2Y11Y1D DATE_ (PRINTED A SIGNATURE) o� 1 r ,�. 2 LOCAL AGENCY USE ONLY THE STATE I.D. M E CO OSED OF THE FOUR NUMBERS BELOW ✓ COUNTY k JURISDICTION M FACILITY M TANK k STATE I.D.# m I I I I � PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC' IN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOS' MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT Pl '.LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 'GROUND STORAGE TANK REGULATIONS FORMS (6-95) 1 i 1%mw