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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Wy�r� . 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 PERMANEN CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REM VIED -' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4a. 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: t C. DATE INSTALLED(MOIDAV/YEAR) �.o D. TANK CAPACITY IN GALLONS: i - II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A [ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E] 80 EMPTY PRODUCT ID 1G PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL EllcMIDGRADE UNLEADED ❑ 5 JETFUEL E] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEMD.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: 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 FIBERGLASS ❑ 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 ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 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 ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,eh. SPILL CONTAINMENT) R) OVERFILLPREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES NO IKER PLATE YES yG NO_ DISPENSER CONTAINMENT VES ✓ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION ,2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A /2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER G MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A C4 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 ASU 9 GALVANIZED STEEL A U 10 CATHODICP TON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MELIW0I NE OF ❑ CNN U 2 UNE TGIVNEM IINI1Wa Imusl Ink 4 EIEC910MC UNE 5 AW =PNP ❑1 10Ec oR TESnNG www1w NAx IIEIFGTOR vtnl lWII ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 ANNUAL RECOUAL NCIUATIONORY ❑ 3 MONITORING ZE 4 GAUGING AUTOMATIC TANK ❑5 MOON TORINGOUNDWATER F-16 TESTINGTANK ❑ 7 CONTINUOU INTERSTITIAL ❑ 8 SIR E] 9 TANK LY MANUAL [:]10 MONTHLY TANK E] 95 UNKNOWN ❑ 99 OTHER TTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNH 3.WAS TANK FILLED WITH YES ❑ NO❑ _ SUBSTANCE REMAINING GALLONS TMATERIAL? THIS FO M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME //�' T 4 DATE (PRINTED a SIGNATURE) Me4k LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW o COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 7371 11 l(o PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE ['Ll THIS FORM MUST BE ACCOMPANIED BYAPERMITAPP�N-FORM A,UNLESSA CURRENT FORMA HAS BEEN FILED. �MUSTBECOMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS °Q� FORM (6.95) Z 1 4 1��