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STATE OF CALIFORNIA `- STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;� — "• s , . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F7I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED — EL5- DBA OR FACILITY NAME WHERE TANK f5 IN 1 , _ , I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A- OWNER'S TANK I.D.# B. MANUFACTURED BY: / G. DATE INSTALLED(MO/DAYl1'EARD. TANK CAPACITY IN GALLONS: } �(�rd , II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C ❑ 1. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AlIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL L-32 PETROLEUM ❑ 84 EMPTY PRODUCT ❑ 1c MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ B MBS ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) C. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S-q: : 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 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLEWIFRP {Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ��❑yyy 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING I y�'B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 11 COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 99 OTHER PROTECTION 95 UNKNOWN ❑❑ $ CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLER(`! R) OVERFILL PREVENTI N EQUIPMENT INSTALLED(YEAR} E.SPILL AND OVERFILL,etc. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT ES 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 FLEXIBLE PIPING Acu)99 OTHER B. CONSTRUCTION A&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 Y/1 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 STEEL WFCOATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL 61NE LEAK 2 UNE TIGHTNESS �1 3 CONTINUOUS INTERSTITIAL L]4 ELECTAUNIC LINE O 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR ❑ TESTING I� MONITORING LEAK DETECTOR SHUYOOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION INVENTORY ❑ 3 VA O RING ❑ 4 GA GMGAUTOMATIC TANK ❑ 5 MON70RINGOUND TER ❑ 6 TEST"hlUALGTANK ❑ 7 MONITORING NG INTERSTITIAL ❑ B SIR ❑ TAEMK GAUGANGAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# '� TANK# STATE 04 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 P hTC�E THIS�RM WITH��THEOCAGENCY[MPLEMENTING THE I�GROUND STORAGE TANK REGULATIONS FORM B (6-95) �� •■w wz Y!J