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• STATE OF CALIFORNIA • °"�.�`'� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE *L 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I '•• I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) -. /- D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY1 PRODUCT ❑ 16 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL Ate-'^ ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Sa 2 LEADED ❑ 99 OTHER(OESCRIBE IN ITEM D.BELOM 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 X 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 5 i BARE STEEL F__] 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 ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING � LINING OR ❑ 5 GLASS LINING ;„L,_6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES— NOL\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. 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 APPUCABLE A. SYSTEM TYPE At U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 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 U ) 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 i NECWWICAL UNE LFNL 2 TINE iY.il6NE33 3C INIERSTTAL ❑4 ELECTRONIC UNE ❑5 AUMIATIO PUNP ❑ 99 OTHER D. LEAK DETECTION ❑ I»:1Ecrcn TEmxc ❑ LwNrORM IE4K DETEcroR sxuroowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADMONRORING E] 4 AUTOMATGAUGINGIC TANK ❑ 5 GROUND MON TORINGTER 6 ANNUALTt -INGTANK ❑ 7 CONTINUMONITORU INTERSTITIAL [:18 SIR ❑ 9 WE K LY MANUAL E:]10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYN 2.ESTIMATED QUANTITY OF /�- 3.WAS TANK FILLED WITH YES ❑ NO _ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TFACILITY# TANK# STATE I.D.# I I I 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 PfFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE fERGROUND STORAGE TANK REGULATIONS FORM B (6-95)