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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT Ll6 TEMPORARY 4 AMENDED PERMIT 7 PERMANENTLY CLO ❑ TANK CLOSURE 8 TANK REMOVED Q 9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNER'S TANK I.D.M �/ B. MANUFTACURED BY: C. DATE INSTALLED(MO/DAY/9EAR) V 1 D. TANK CAPACITY IN GALLONS: I II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- MOTOR VEHICLE FUEL ❑ 4 OIL B.\J�� C la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS PETROLEUM ❑ S0 EMPTY 1U l PRODUCT ❑ lb PREMNE4 UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ]D:3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDORADE UNLEADED ❑ 5 JET FUEL ❑ 8 M&5 ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ED 2 LEADED 99 OTHER(DESCRIBE IN REM D.BELOW) C.A S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E fA. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM❑ ❑ 95 UNKNOWN EM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT ❑ 99 OTHER K 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC RIAL5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP y Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER IOR ❑ I RUBBER UNED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 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.EXTERIOR ED1 POLYETHYLENE WRAP 2 COATING CORROSION ❑ ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONE�r'91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,MC. SPILL CONTAINMENT INSTALLED(YEARI OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPUCABLE 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 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A V 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 ❑I -°'x1°-UNE OF [:]2 Jai TIG14'I ss 3 m..000.wrERsmuL �4 ELEC IC USE ❑5 AW M Ilc Pars DE aE TESTN6 MONTOBRp LFAN DETECTOR SNUfOOWN ❑ 99 OTTER V.TANK LEAK DETECTION E] 7 CONTINUOUS INTERSTITIAL 2 MANUAL RECONCILIATION ❑ 3 MONIITORING OZE ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND MONITORINGTER ❑ 6 TESTINGTANK MONITORING ❑ e SIR ❑ 9 TANEKLY K GAUGINGTES7ING AL ❑10 Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PI-ACE) L ESTI TE SEDlJMO/DAY/YR) 2.ESTIMATED QUANTITY OF -� 3.WAS TANK FILLED WITH t_ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF;PERJUR ,AND T- THE BEST F MY KNOWL DGE, IS TR E A DCORRECT AN OWNER'S NAME /n� PRINTEDd51GNATUREI ('�L u (I�l. �, ( fyf f 'tel. DATE/ /J/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (' COT LJ_JN JURISDICTIONN FACILITYN T STATE I.D:# I -I � NK„��---�-�----^�`^^ PERMIT NUMBER PERMIT APPROVED BY/DATE �L- I FERMI T EXPIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORMS (6-95) t� SHOULD BE ACCOMPANIED BY A PLOT PLAL' 9LE THIS FORM WITH THE LOCAL AGENCY.IMPLEME GROUND STORAGE TANK REGULATIONS ENT! TH