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• 'CCOunCCe STATE OF CALIFORNIA •. q� STATE WATER RESOURCES CONTROL BOARD .. - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. Wpk MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S e /T IV e C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) , 5 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL d OIL B. C, ❑ 1a REGULAfl UNLEADED ❑ 3-DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 'KB0 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ l0 MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW] D. IF(AA)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED O C.A.S.k gr 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 B. TANK '5i,r 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 W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_x D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION / 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,8t0. SPILL CONTAINMENT INSTALLED C(EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES 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 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DQUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A o 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 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 D. LEAK DETECTION ❑1 MEGW Id LME(FAN ❑2 UNE TIG NESS ❑3 CO U.U.INTER AL ❑4 E 2M.IC UNE ❑5 AUTOIMTIC Puw OETECmR TESTING MOMTgI#1G LEAK CEIECTOR 6YOTOOWN 9 OTHER V.TANK LEAK DETECTION Ul 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION TORY�❑ 33 VADOZIE MONITORING ❑ 4 GAUGINGIC TANK ❑ 5 MONITORINGDWATER ❑ 6 ANNUAGTANK 7 MONITORING INTERSTITIAL ❑ TIN a SIR IZ\TANK LY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMA ATE LAST SED( R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO 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# TANK# STATE I.D.# 5 3 0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN -"-"ROUND STORAGE TANK REGULATIONS FORMS (6-95)