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o. e � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD uym� e o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ; - , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED ONSITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6'i'A''WJ 5 t�- '�\ - a 2- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# I B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) R l 6 D. TANK CAPACITY IN GALLONS: 1 2 OQ II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C. a REGULAR UNLEADED O 3 DIESEL O 6 AVIATION GAS A F-� 2 PETROLEUM O 80 EMPTY PRODUCT lb PREMIUM UNLEADED 4 GASAHOL T METHANOL 1G MIDGRADE UNLEADED O 5 JETFUEL 8 M85 O 3 CHEMICALPRODUCT 95 UNKNOWN 2 WASTE a 2 LEADED 99 OTHER(DESCRIBE IN ITEMD.BELOW( D. IF(A1)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 I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER Q 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK E::] I BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE T ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (PNm9ry TA9k) [�] 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR F-� 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING '�Rr6 UNLINED E�:] 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING E::] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION O 5 CATHODIC PROTECTIONE] 91 NONE Ej 95 UNKNOWN % OTHER E.SPILL AND OVERFILL,eh. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PR VENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE VES NO_ DISPENSER CONTAINMENT VES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A16,h PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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)AW 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U ? 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 D. LEAK DETECTIONQ 1 M:cNNmAL ME(TAX O 2 UNE nGN WEs 3 G NUGUS IM Tm1L 4 ELEcmaNc uxE AurorurK P6EP MGO 99 OTHER DETECTOR TESTING NTGPING lFN(OETELTON SNUTOOwx V.TANK LEAK DETECTION O 1 VISUAL CHECK 2 RECONCILATION ANUAL INVENTORY 3 MONITORING 4 AUTOMATGAUGNGIC TANK 0 5 MONITORING WATER O 6 TESTINGANNUALTANK �] CONTINUOUS INTERSTITIAL 0 8 SIR 0 9 WEEKLY MANUAL 10 MONTHLY TANK O 95 UNKNOWN O 99 OTHER MONITORING TANK GAUGINGI TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TOT BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT -TANK GWMEFWr NAME DATE (PRINTED 8 SIGNATURE) / LOCAL AGENCY USE ONLY THE STATE .N MBER IS COMPOSED OF THE FOUR NUMBERS BELOW CCIILINpf# JURISDICTION M FACILITY# TANK STATE 04 F7-1 = Ill 1111 EL- 111111 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE a 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 T -v. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF""OERGROUND STORAGE TANK REGULATIONS FORM B (6-95) �,