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STATE OF CALIFORNIA +� STATE WATER RESOURCES CONTROL BOARD uyd�, e o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B : _ , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 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.N B. MANUFACTURED BY: - C. DATE INSTALLED(MO'DAWYEAR) I D. TANK CAPACITY IN GALLONS: II.TANK C NTENTS IF A-1 15 MARKED,COMPLETE ITEM C. V I A 1 MOTOR VEHICLE FUEL Q 4 OIL B. / C. ❑ 1a REGULAR UNLEADED 3 DIESEL Q 6 AV17ONGAS /1( CTyJS ❑ ib PREMIUM UNLEADED 4 GASAHOL 7 METHANOL Q 2 PETROLEUM Q SO EMPTY 1 PRODUCT 1c MIDGRADE UNLEADED5 JET FUEL Q 8 M85 03 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELO'M D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D AND E ID l A TYPE OF El I I DOUBLE WAIL O 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM Q 95 UN SYSTEM ❑ 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT Q 99 OTHER B. TANK ❑ 1 BARE STEEL Q 2 STAINLESS STEEL Q 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 0 5 CONCRETE O 6 POLYVINYL CHLORIDE Q 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Q 2 ALKYD LINING 3 EPDXY LINING Q 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Q 6 UNUNED O 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10014 METHANOL? YES / NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP Q 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODICPROTECTION a 91 NONE O95 UNKNOWN O W OTHER SPILLCONI NMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,M9. DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES— NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 YECAI M UNE LF. LNE TMN111EE4 f/JmNUWa NRERSTIIAL ELECIRONL UNE 5 A9NOI M RAP OTHER D. LEAK DETECTION Q oET ww ❑2 TEsnNo ❑3 uoNTauA1 Q4 TAK oETEcroR ❑ slulooxv [:] 99 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK O 2 RECO CILIATIONORY O 3 MONNIITORING 0 4 GAUGING TANK ❑ 5 MONITORING ❑S TESTINGTANK ❑ B SIR 7 INTERSTITIAL A � AGGALO10 MS Y TANK O 95 UNKNOWN Q 99 OTHER MONITORING NG EG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO SUBSTANCE REMAINING 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) Z LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION N FACILITY N 7� S TANK N 00& STATE I.D.# m U Sl / 1-6-111 1 6 0 IP 13 119 1 8 119-7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS ACURRENT FORM A 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 REGULATIONS FORM B (6-95)