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• • nCEO STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B er , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SED nN.SLEE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 66TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: s- v -7 f`L 5 / z- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.0.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF IS MARKED,COMPLETE ITEM C. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY —'1 1 PRODUCT ❑ 1C MIDGRPDE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El 2 W,1STE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM D.BELOM D. IF(A.1)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 BOX D AND E A. TYPE OF ❑ 1 DOUBLE 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 S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL Ek95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ��❑III 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ III 6 UNLINED y` 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001A METHANOL? YYES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. 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 APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Aa:;05 UNKNOWN A U 99 OTHER 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AGPI5 UNKNOWN A U 99 OTHER - 1 MEGUMCAL UNE LEAK 2 UNE TIOKI N 3 CDNRNUWS IWE R`ML 4 ELECPKNIC UNE 5 AMONATIC PUMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR ❑ TEmNc ❑ MoxlTonlxc ❑ LEAK DETECTOR ❑ sxuroovm ❑ V.TANK LEAK DETECTION ® e� ❑ 1 VISUAL CHECK Ea 2 MANUAL INVENTORY ❑ 3 MON FIN ❑ 4 GANO IC TANK ❑ 5 MONITOR 'T 6 TESTINANR�UALGTANK ❑ 7 MONITORING G INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY U ANGAL ❑10 MESTINGY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ 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 NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m = Eljzegy ® v7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA ON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOU C BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95)