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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iye1� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ON SITE ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S S # 9 - 2 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.• B. MANUFACTURED BY: eP C. DATE INSTALLED(MO/DAYNEAR) C D. TANK CAPACITY IN GALLONS: QO II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. 1e REGUWi UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM O 80 EMPTY 1 PRODUCT ❑ 1D PREMMM UNLEADED O 4 GASAHOL ❑ 7 METHANOL lc MIOGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E r�7 A. TYPE OF IIT 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM L.J 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tok) a 9 BRONZE Q 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED 2 ALKYD LINING 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR O 1 POLYETHYLENE WRAP ED 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION gl NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION E::] ❑ ❑ E SPILL AND OVERFILL,BTC. SPILLCONTAINMENT INSTALLED(YEAR OVERFILL PR ENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO� STRIKER PLATE YES NO DISPENSER CONTAINME 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 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 W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECKKNIGLL uK LEAK ❑2 LNE IXa n 3 c«rtwuaS IMER4TmAL Y.-l14 ELEMMIC u E 5 AWTC NW ❑ 99 OTHER OETECfOR lE3IN9 KCNTd LTJ IFAK O CTOR SXUi1lOWN V.TANK LEAK DETECTION 1-1 1 VISUAL CHECK 2 RE�COUNCILIATIONORY ❑ 3 MODNOITORING `i'.' d GAUGING MONITORING TANK ❑ 5 MONTORINGTER ❑e TTEEBTNGTANK "--"7 COINUOUS MONITORING INTERSTITIAL ❑ 8 SIR E] 9 WEKTANKLAUGINUAL ❑ 10 TESTINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 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 TOT EST OF MY KNOWLEDGE,IS TRUE AND CORRECT TMJICpYRO!•R'B-NAME DATE aloe I (PRINTEDA SIGNATURE) d 'S O� LOCAL AGENCY USE ONLY THE STA .D.NU BER IS COMPOSED OF THE FOUR NUMBERS BELOW CO N JURISDICTION# FACILITY# TANK B [C STATE I.D.# m [PER:MITUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE r 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 THF"'IDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)