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.. ..i STATE OF CALIFORNIA a`% STATE WATER RESOURCES CONTROL BOARD �ywt� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED ONSITE ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V& C/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: p / J II.TANK C TENTS IF A-1 IS MARKED,COMPLETE ITEM C. V A. 1 MOTOR VEHICLE FUELa 0 OIL B. C. L-' to REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS O 2 PETROLEUM O 80 EMPTV 1 PRODUCT ❑ 1B PREMIUM UNLEADED O 4 GASAHOL 0 7 METHANOL Q 1c MDGRADE UNLEADED O 5 JETFUEL O 8 MBS O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER(DESCRIBE IN TEND.BELOW) D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,ND ALL THAT APPLIES IN BOX D AND E A. TYPE OF O 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM Q 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE O 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM E:] 8 100% METHANOL COMPATIBLE W/FRP (PNlnary Tank) a 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER C.INTERIOR F__j 1 RUBBER UNED O 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC UNING LINING OR O 5 GLASS LINING O 6 UNLINED 0 95 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR F__l 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 0 5 CATHODIC PROTECTION O 91 NONE O95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,BK. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKERPLATE 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 S. CONSTRUCTION A U 1 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 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 W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 MECK.xuL uxE uAN 2 IME TX,HTNESS 3 CWIN=S NTERSEGIAL 4 REMONIC LINE 5 AUroNnTIC PUry DETEam TESTIN9 0 Mowmim LEAN DETEMR 0 SHUTDOM Q 99 OTHER V.TANK LEAK DETECTION O 1 VISUAL CHECK O 2 MANUAL RECO CIUATIONORY O 3 VADOZE MONITORING D / GAUGING C TANK 0 5 GROUND MONITORINGTER O 6 TTEESTINGTANK a 7 CONTINUOUS MONITORING INTERSTITIAL 8 SIR ❑ 9 TANK GAUGING O 10 T1 STINGY TANK O 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DATE LAST USED(MO/DAY/YR) 'J' I' Q 2.ESIMATED OUANTITY O . SUTBSTANCE REMAININGF GALLONS 3 W�INERT MATERITANK FILLED AL 7H YES8O NO O THIS FORM HAS BEEN COMPLETED UN/DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE,a ^ (PRINTED A SIGNATURE) Y k7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#6 r7y TANK# WIL STATE I.D.# 7M PERMIT NUMBER PERMIT APPROVED BYIDATE 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 COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TF OERGROUND STORAGE TANK REGULATIONS FORM B (6-95) %W I"EW