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STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ ONE REM 5 CHANGE OF INFORMATION `,❑ 7 PERMANENTLY CLOSED ONSITE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE X8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �` I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAYNEAR) D. TANK CAPACITY IN GALLONS: 0,0 In II.TANK C NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL4 OIL B. I� C ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY � ' PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTEI❑. 1C MIDGRADE UNLEADED ❑ 5 JETFUEL E] 8 M85 < LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) � D. IF(Ai)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 B ANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ a 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEE ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN E:] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1X% ANOL7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING CORROSION ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INS LED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT-YES_ NO IV.PIPING INFORMATION CIRCLE IF ABOVE GROUND ORUIFUNDERGROUND BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTIONg LE ALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND EL A U 2 STAINLESS STEEL p U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSIONINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTIONANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIOAL UNE L6\N ❑2 WYE nGHTNESS ❑ IXffIN0003 INTEg3TITIAL ❑4 ELEM MC UNE ❑5 AUTOMATIC PUMP TESTING AK DETECTOR SHUTDOWN ❑ 99 OTHERV.TANK LEAK D ❑ 7 OONNNUOUs INTERS SUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 MONIITORING ❑ 4 AUTOMATGAUGING IC TANK O 5 GROUND MONITORINGTER ❑ 8 TESTINGTANK MONITORING ❑ 8 SIR ❑ 9 pNRGAUGINGLY AL ❑ IU TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# I 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 ::1 COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (6.95)SHOULD BE ACCOMPANIED BY A PLOT PWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE �RGROUND STORAGE TANK REGULATIONS 9 -3- 97oe7