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• • aou. a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Y d� UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 2 _ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: E / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.0.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ,,��yy�L 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ BO EMPTY PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED E] 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E yyy�� r-11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 4Q 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ fi POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ��❑II 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINM- I I INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BLC. DROP TUBE VES_ NO_ --jTRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 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 U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 CATHOOICPROTEC71ON �' S UNKNOWN A U 99 OTHER 1 MECX4NILAL NNE IFA)( 2)INE nGMNEdd ❑3 WNnNGWd INn:PFTITAI ❑4 ELECTRONIC LINE ❑5 AUfOAUTC PIINP ❑ 99 OTHER D. LEAK DETECTION ❑ GMMIR ❑ TE6nNG MGMTGRING )FAX OErecrGR sxuloovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADMONIOZETORING ❑ 4 GAUL NGC TANK ❑5 MONITORINGDWATER �ANNUA7MONINUOU INTERSTITIAL B SIR ❑ 9WE KLY MANUAL ❑10 MO T HLY TANK ❑ 95 UNKNOWN NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE 1N-PLACE) MATE DATE ��/// 1.ESTIT USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:] NO �jF G� SUBSTANCE REMAINING O GALLONS INERT MATERIAL I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# 15 � 1 O 1 1 1 :LjF�lwv'7z PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PORLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ERGROUND STORAGE TANK REGULATIONS FORMS (6.95)