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- STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑// 8 TANK REMOVED Q� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , (� r I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: D II.TANK C NTENTS IFA-11SMARKED,COMPLETE ITEM C. Je A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS PRO ❑ 2 PETROLEUM ❑ 80 EMPTY 1 DUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1e MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)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 ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM X2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK _W< BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 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 LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO'—'* D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION E] 5 CATHODIC PROTECTION PROTECTION W91 NONE D 9 UNKNOWN E::] 99 OTHER I III E.SPILL AND OVERFILL,8[C. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENT( N UIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE 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 Z,1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A w SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 MECHANGL UNE UT K ❑2 UNE TIGNiNEEG 3 CCMINUWG NfERG1RiAL ❑4 ELECTRONIC UNE O 5 AUTOMATIC PUMP ❑ 99 OTHER GETECiOP TESTING M0111TORING TJAK GEiECTOR GHUf00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 gECOAL IN EONORY ❑ 3 MONOITZE ORING E] 4 AUTOMAT GAUMGIC TANK [:] 5 MON GROUND D WATER ANNUANG TESTING ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK GAUGING ❑10 MESTINGy TANK ❑ g5 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) I.ESTIMATED DATE T USED(MOIDAYNR) 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 DATE (PRINTED d SIGNATURE) -T LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Rec, CJL COUNTY# JURISDICTION# r FACILITY# TANK# STATE I.D.# m I I I 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 PL�ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEORGRO��STORAGEREGULATIONS V FOR0M4&R7 FORM B (6.95)