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N � n'ea STATE OFCAUFORNIA °a, a STATE WATER RESOURCES CONTROL BOARD daaa� e UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B > _ 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ d 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 I.D.I B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ to flEGUTAfl UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ Ic PREMIUM UNLEADED ❑ 4 JET FUEL ❑ 8 METHANOL ❑ tc MIDGRME UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: 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 ❑ I DOUBLE WALL F7 ❑3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (P(9RU)'TMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EKTERIOR ❑ 1 POLYETHYLENE WRAP .❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E NONE SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION.EDUIPM NT DISPENSER LED(YEAR) CONTAINMENT E.SPILL AND OVERFILL,BTC. ppOp TUBE VES_ NO._ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU I 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 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 B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION / McCXANICAL UNE LTM 2 AWE TIGHTNESS 3 COMINUWS WTERSR11.1L d BECRIONC DNF 0 5 AIrt01MTCSNUIOOWN mw O 99 OTHER OFIECTOR TESIANO W MTMNG TEAK GEIECTOP V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCIUATIONORY ❑ 3 MAODNIITORING OZE ❑ d GAU NG AUTOMATIC TANK ❑ 5 MON TORINGGROUND TER ❑6 ANNUALTESTING ❑ 7 CONTINUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANMANUAL ❑ W MOT NG HLY TANK (,a 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE AN-PUCE) i 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO .ESTIMATED DATE LAST USED(MOIDAVNR) ❑ 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 DATE TANK OWNERS NAME (PRINflD6510NATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION N FACILITY N TANK STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYMATE 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 Pie THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�ERGROUND STORAGE TANK REGULATIONS FORM B (6-95)