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STATE OF CALIFORNIA •°" ,� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B ;A , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT F76 TEMPORARY TANK CLOSURE 8 TANK REMOVED ZIDBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5z- 1. . TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y B. MANUFACTURED BV: ' C. DATE INSTALLED(MOIDAVlYEAR) Cj D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A R�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1b PREMIUM UNLEADED E] d GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 00 EMPTY PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT F-195 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMD.BELOY) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSIIT��TRR,RUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF LJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM rIJI 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.E7(TERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 5 CATHODICPROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) NO__ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ E.SPILL AND OVERFILL,SLC. DROP TUBE YES_ NO PROTECTION IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 7 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a 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 1 MECKWICAI UNE IFAK 2 LINE iN;MNESG 3 INUOUS INTEPSTITIAL ❑4 EIECiRONIC UNE ❑5 AUIGMATIC PUNP ❑ 99 OTHER D. LEAK DETECTION ❑ =M0'R ❑ TESTIM ❑ GNiTORING 1FAx pEIECTOR srlUloowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANU EDO ❑ 3 MONIITORING ❑ 4 GA NGAUTOMATMONITORING TANK ❑5 GROUND MONTORINGTER ❑ B ANNUAL TESTING ❑ 7 MON TORWG INTERSTITIAL ❑ 8 SIR ❑ 9 TANKLY MANUAL ❑ 10 TIS INGY TANK ❑ 85 UNKNOWN ❑99 OTHER GA 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 (PRINTED 8 SIGNANRE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# .r- STATE I.D.# ® 1 11 178 g�� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION GATE I V !J THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A.UNLESS A CURRENT FORMA HAS BEEN FILED. F C GROUNDMUST BE COMPLETEDN R REGULATIONS S. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THRGROUND STORAGE TANK REGULATIONS FORMS (6A5)