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t 1 � • .«s r STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p` I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: 79usc D C. DATE INSTALLED(MO/DAYIYEAR) 9�C0 D. TANK CAPACITY IN GALLONS: �.l II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A —]2 PETROLEUM ❑ 80 EMPTY X 1 PRODUCT ❑ 1b PflEMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL !^'_ ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE 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 X 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 -'V1R 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL E:] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E] 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 E] 4 PHENOLIC LINING LINING OR 115 GLASS LINING 74 6 UNLINED E] 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WIWITH 100% METHANOL? YESX NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC CORROSION /-' PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,#TC. DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A V SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 MECWWILAL UNE IF_4N 2 UNE TIGWKSS CONTINUWS IWERSTITMI 4 FLECnttN11C UNE 5 AUfOMABC PUMP 89 OTHER D. LEAK DETECTION GETECTGR ❑ resmal MONITORING ❑ LEAN OETEOroR ❑ Sxu100WN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCIUATIONINVENTORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING TANK ❑ 6 GROUND,MONITORING TEST ❑ 6 ANNUAL TANK 7 CONTINUOUS MONITORING INTERSTITIAL ❑ B BIR ❑ 9 TANK GAUGINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTIN THER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATE DATE LAST USED(MODAY/YR) 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 A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY�ACILITY# TANK# STATE I.D.4 m Q PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 71 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK(((R]]]E....GUL�A.TTIIONS