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STATE OF CALIFORNIA p i� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: v _ C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: AlOpv, II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. �� A, � 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR UNER E) 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 W/FRP (PEImmy Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 14QS UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING (((E] 3 EPDXY UNING E:] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNUNED T.{I 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? `VEESS\— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTIONSINGLE 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 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 &'Ir--A UNKNOWN A U 99 OTHER D. LEAK DETECTION [::]I WCUNE L 2 UNE TKJRNESS 3 OOMINUWS INTFASIIRA 4 ELECTRONIC UNE ❑ L@ 5 AUTOWTIC PU 001 ❑ TESTING ❑ MONTORING LEAK O CTOR OENWI EAK EHUT m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONIITORING OZE ❑ 4 AUTOMATIGAUGING MONITORING TANK ❑5 GROUND MONITORINGTER E:] ANNUALTANK e TESTING ❑ 7 MON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL E]10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE T U DIM AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO "� SUBSTANCE REMAINING d GALLONS INERT MATERIAL? ❑ ❑ 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 I.D:# 3" [ Y ,. j �� PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 12-ICI 9S THIS FORM MUST BE ACCOMPANIED BYA PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIO .THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEIWGROUND STORAGE TANK REGULATIONS FORM B (6-95)