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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMF MARK ONLY ❑ 1 NEW PERMIT ► ' / 'n CLOSED ONE ITEM ❑ 2 INTERIM PERMIT El , I f///U ►�// 7 PERMANENTLY CLOSED ONSITE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- A OWNER'S TANK I.D.# C. DATE INSTALLED(MO/DAY/YEAR) II.TANK CONTENTS IFA-1 IS MARKED,COMF FD. IF 1 MOTOR VEHICLE FUEL ❑ 4 OII ` ERA. 3 DIESEL ❑ 6 AVIATION GAS2 PETROLEUM ❑ 80 f { ' n f 4 GASAHOL ❑ 7 METHANOL3 CHEMICALPRODUCT ❑ 95 1 \"•l •T///r^/ 5 JET FUEL ❑ B MB5 99 OTHER(DESCRIBE IN REM D.BELOW))IS NOT MARKED, ENTER NAME OF SUBSTAI ^ ' .#: III. TANK CONSTRUCTION MARK ONE ITEM A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH E><'rm.,,..._ ERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 UrHER 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 W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED �❑ 22 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING IyT'e UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO)<- D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION�91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,a1C. SPILL CONTAINMENT IN''S''T''�AVIL0 (V ) OVERFILL PgEVENTION 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 Ej 1 MECHAMO UNE IF_11( UNE TM,NINESS O 3 CONTINUOUS INTERST1IPL ❑q EIECmgV10 UNE EIA Uf01MTIC PUMP DETECTOR TESTING MONITORING L811(GE1ECttlR SNUi00WN ❑ 99 OTHEq V.TANK LEAK DETECTION 1 VISUAL CHECK 2 MANUAL ❑ 7 MONITORING INTERSTITIAL O B SIRRECONCILIATIONORY ❑ 9 4MVOONITOYRMANUAL ❑ 0 MON HLY TANK4 AUTOMATIC ❑ 5 MON TORINGGROUND THR TESTINGTANK ❑ TANK GAUGING ❑ TESTING ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST�OFMIIKNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION It FACILITY# 4'-a O PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E% THIS T BE ACCOMPANIED BY A FORMC MUST BE CMPLETED FOR B (6-95)RMMU SHOULD BE ACCOMPANIED BY AI PLOT PC ATION FORM WLE HIS F-FORNIAORM WITH HE LOCAL AGENCY IMPLEMENTING E TING THE UNLESS A CURRENT FORMA HASBEENFILE . RM RGROUND STORA TANK RIEGULATIONSNS. THIS FORM ✓ Ilea('�6,W