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• STATE OFCAUFORNIA • ^`'o,,,« STATE WATER RESOURCES CONTROL BOARD �� oma' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON E ONE ITEM 12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 _-�L93 .` , )Lil ,, `•�I' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN or A OWNER'S TANK I.D.# B. MANUFACTURED BY: [ C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A �41 MOTOR VEHICLE FUEL ❑ 4 OIL B. CIS REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS [72 PETROLEUM ❑ 80 EMPTY PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E7] 2 WASTE ❑ Ic MIDGRADE UNLEADED E::] 5 JETFUEL ❑ 8 M85 ❑ 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 A. TYPE OF ❑ 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM )ef2�2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD WI 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 ❑ I RUBBER LINED �❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING I7q 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITH100% METHANOL? YES_ NO,)e D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION Nmr 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSO. SPILL CONTAINMENT INSTALLE (YEAR) OVERFILL PREVENTION UIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE VES NO DISPENSER CONTAINMENT YE _ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 'SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Alo 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 O 1 MECHINIGAL UNE UE K 2 UNE nGWKSS ❑3 w MNUOUS uRERSIIn.KL d ElECI60NIC UNE 5 AmoMAnc PMMA OETECiOP TESTING MONITORING LEAK DETECTOR SHMMM [:] 99 OTTER V.TANK LEAK DETECTION 25; j� ❑ 1 VISUAL CHECK 25; RECONCILATIONMANUAL ORY ❑ 3 MONIITORING ❑ 4 GAUGING TANK ❑ 5 GROUND MONITORING TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL F] 10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER TANK GAUGING TESTING ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE ST11SED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �'�' SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ 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 E SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION If FACILITY If TANK# STATE I.D:# I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIPATION 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 FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PLIfLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS � � � FOR0034&R7