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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :n 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 SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �� 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.k B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/VEAR) S D. TANK CAPACITY IN GALLONS: G II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A I, I 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. [:j 1. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS a�J ❑ ❑ is MIDGlb IRADE UNLEADED ❑ 5 JENLEADED 4 T FUEL ❑ 8 M85HANOL ❑ 2 PETROLEUM 80 EMPTY � 1 PRODUCT ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.B 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.8,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F71 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 W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOQ, D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONgt 1:1 95 UNKNOWN ❑ 99 OTHER PROTECTION [:35 CATHODIC PROTECTION- NONE y SPCOTAINMENT INSTa ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(VEAR) E.SPILL AND OVERFILL,etc. DRILLOPTUBNE 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 12)1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A,j I 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 SEEL W/COATING A U 8 1001/6 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑1 NECWNILAL IME LEA)( 2 UNE TIGWNEW ❑3 CIXmNU01A-IN .RSNBAL ❑4 EIEC 05tscONIC UNE ❑5 AGTDNADL PUNP 99 OTHER omcroR TESnNG uoM7oeMG rFAN DEtEcroR sNumowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 GAUGINAUTOMATG MONITORING TANK ❑5 MONTORINGGROUND TER 6 ESTINGTANK RECONCILIATION MONITORING ❑ 7 MONTORNG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MOTHLY TANK ❑ 85 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) . 2.ESTIMATED QUANTITY OF /�1r 3.WAS TANK FILLED WITH YES ❑ NOL+ 1.ESTIMATED TE T USED,(MO/DAVIYR) SUBSTANCE REMAINING kms/ GALLONS INERT MATERIAL? "t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C�OUNT�Y# JURISDICTION# FACILITY# TANK# STATE I.D:# � = �= PERMIT NUMBER PERMIT APPROVED BY/DATE 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*FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THfERGROUND STORAGE TANK REGULATIONS FORM B (6-95)