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1 • • °ea STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD +` q 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 INFORMATION 7 PERMANENTLY CLOSED ON SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 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 1.0.# d— S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAV/VEAR) 7 D. TANK CAPACITY IN GALLONS: 62 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. g 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8' C ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL /❑'—`2 PETROLEUM ❑ 80 EMPTY >< PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(OESCRISE IN ITEM D.BELOW) 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 ❑ I 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 ❑ I 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 ❑ 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 x 6 UNLINED ❑ 95 UNKNOWN ED 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NOL\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENT ION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE VES._ NO__ STRIKEfl PLATE VES_ NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A 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 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 W/COATING A U B 100% METHANOL COMPATIBLE W/PRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECNNaCAL LINE UE K NNE BGInhESa 3 CONRNUWS IMERSTIIIAL ❑4 ElE01 lc NNE O 5 AUfONABG PUMP 9 OTHER OETEOTOR TESTING MONITORING LMN DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK MANUAL INVENTORY ❑ 3 MONO ORING ❑ 4 AUTOMATGAUL NGIC TANK ❑ 5 MON TORINGGROUND TER�6 TESTNGANNUALTANK ❑ 7 MONTORWG INTERSTITIAL ❑ a SIR ❑ 9 TANKGAUGINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE 1N-PLACE) 1.ESTIMA DDATE LASTUSE M AV/YR) 2.ESTIMATED QUANTITY OF� 3,WAS TANK FILLED WITH VES ❑ NOJPCI _ _ 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 DATE TANK OWNER'S NAME (PpMTED a 31GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY If TANK#QO2 STATE I.D.# � a s 1 3 a ° TaFav 10 14;14 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 3 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 POFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF RGROUND STORAGE TANK FORM B (6.95) 4