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ptyougc.°s co STATE OF CALIFORNIA 4 �. STATE WATER RESOURCES CONTROL BOARD o 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 kNFORMATICN ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# , S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYYEAR – D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 1 PRODUCT ❑ 1h PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ is MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT L] 95 UNKNOWN ❑ 2 WASTE 2 LEADED, ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.H 111. 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 ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE El 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 ❑, 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 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE E] }5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑- SPILT.CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTIQN EQUIPMENT INSTALLED(YEAR) ' E.SPILL AND OVERFILL,I?tC. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND 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 A U 99 OTHER B. CONSTRUCTION g U 1 SINGLE WALL A U 2 DOUBLE WAIL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U !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 WI COATING A U g 100% METHANOL COMPATIBLE WlFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL UNE LEAK2 LINE TIGHTNESS ❑3 CCNTINUOUS INTERSTITIAL f-�4 ELECTRONIC UNE 1:15 AUTCMATIC PUMP`Via., 99 OTHER 1. D. LEAK DETECTION Ll DETECTOR ❑ TESTING MONITORING LJ LEAK OETECTOR SHUMOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION MONITORING ❑ 3 MON ORING ❑ 4 AUTOMATGAUGING IC TANK 5 GROUND MONITORING TER ❑ 6 TESTINGTANK ❑ WEEKLY MANUAL 10 MONTHLY TANK95 UNKNOWN ^99 OTHER 7 CONTINUOUS ANKGAUGNGTETIN ❑ MONITORING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOlDAYIYRJ 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 4 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DAl'E TANK OWNER'S NAME (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# "`- STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE WGROUND STORAGE TANK REGULATIONS FORMS (6-95)