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Ift f STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Fol 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED,Ary.SQE -. ONE REM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNEFVS TANK I.D.It '% ., B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) �(� '�� D. TANK CAPACITY IN GALLONS: OO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A t. ?g'1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. 1e REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ®',,.1 PRODUCT 1b PREMIUM UNLEADED 4 GASAHOL 7 METHANOL ❑ tC MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 0' 2 WASTE 2 LEADED H 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A7)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 ❑ 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 Tr7l BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL u 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (P"—'y TenYJ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �'6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP -2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ED CATHODICPROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILLCONTAIN MENT INSTALLED�1'EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO STRIKER PLATE YES_ NO G`. DISPENSER CONTAINMENT YES_ NO 2L IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A i.�Y 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A .U,I 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A o 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MECI O'AI UK LEAK 2 UNE 1NwrxEw ❑ m 3 NnNUouIRIERSMAL 4 EIEC S C UK 5 AUroMA11C RIAV ❑ GETECIOR ❑ Ic TESiNG IIGM wm ❑ IEMI OElECT011 ❑ V111IMM E:1 99 OTHER �� V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RM Cp CIUATIONAL ORY ❑ 3 VADOZEMONITORING O 4 GAUGINAUTOMATG MONITORING TANK ❑5 GROUND MONTORINGTER ❑ 6 ANNUAL TESTING ❑ 7 CONTINUOUS Ej 9 AEMANUAL ❑ 10 MO NTHLY TANK� 95 UNKNOWN 99 OTHER MONITORINGB INKNGS VI. TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DA LAST USED(MWD NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 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 TANK D&NEWS NAME �/ 6 DATE (PRINTEDA SIGNATURkT rk'I 1/s Av _I LOCAL AGENCY USE ONLY LTHCE'STATE I.D.NUMBER IS COMPO ED OF THE FOUR NUMBERS BELOW COUNTY k JURISD M FACILITY L�W TANK k STATE L .1 D:# PERMIT NUMBER PERMIT APPROVED BYIDATE 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&FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�ERGROUND STORAGE TANK REGULATIONS FORM B (6-BS)