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STATE OF CALIFORNIA =<; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 f C..� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M D / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) 73 D. TANK CAPACITY IN GALLONS: D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 7b PREMIUM UNLEADED ❑ d GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER IDESCRIBE IN ITEM D.BELOM D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.N: 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 ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL r-14 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 BARE STEEL F-12 STAINLESS STEEL E:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK � MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 8 100°h METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ LINING OR E:] 5 GLASS LINING 6 UNLINED 95 UNKNOWN E::] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE""WWII\ITH 100% METHANOL? YES_ NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION g1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES__ NO BIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUNO OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U Z DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 1 MEGUfAGL ZINE LEAK 2 TINE B6H1NE55 ❑3 CONIINUWa IMERSi1nAL ❑4 ELEC1110MC LINE ❑5 AUTOMATIC PUW ❑ 99 OTHER D. LEAK DETECTION ❑ oETECTOg ❑, TESTING 1014 ro TNG IEAN DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 10 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ING 4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND TER 6 TESTINGTANK RECONCILIATION ❑ 9 WEEKLMONITYMANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER ❑ 7 CONTINUOUS INTERSTITIAL g SIR TANK GAUGING TESTING MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE Iry-PLACE) 1.ESTIMATEDDATELAST US D(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 DATE TANK OWNER'S NAME (PRINTED 6 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNN# JURISDICTION# FACILITY» �TA STATE LD:# � m = rpm PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 P TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TAN REGULATIONS FORM B (6-95) 3