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a' STATE OF CALIFORNIA WP r° cO STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY OSED QNSITE- ONEITEM `=v 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOV / •y DBA OR FACILITY�NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# S. MANUFACTURED BY: - us c C. DATE INSTALLED(MO/DAYNEAR) R D. TANK CAPACITY IN GALLONS: II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- 1 MOTOR VEHICLE FUEL r74 OIL B. C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1G PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D,8ELOVJ 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (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 LINING MATERIAL COMPATIBLE WITH 109% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,CZE. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL REV'ENTION EQUIPMENT INSTALLED(YEAR) PROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO W.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U TF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL AU 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 WICOATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZEDStEEL A� U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER MECHANICAL LINE EAK 2 DNE HTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION 711 DETEcroR T c Mo wTORINc LEAK DETECTOR ❑ SHUTDOWN V,TANK LEAK DETECTION F-1 i VISUAL CHECK E] 2 RMANUAL ECONCILIATIONORY ❑ 3 MONIVADTORING El AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER El ANNUALTESTING 7 MON TORINUG INTERSTITIAL ❑ B SIR ❑ 9 WEEEKLY K GA MANUAL E] 10 MO TING TANK❑ 95 UNKNOWN [71 99 OTHER L TANK CLOSURE INFORMATION(PERMANENT CLOSURE: IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 S SIGNATURE) r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 42 L COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# Val 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 PL FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGRGROUND STORAGE TANK REGULATIONS FORM B (6-95) L)