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• STATE OF CALIFORNIA • i <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `� ma <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4;aCP <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.# /S 1� B. MANUFACTURED BY: �^ V <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> 2 PETROLEUM E] 80 EMPTY 7 PRODUCT <br /> REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS <br /> q, MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ib PREMIUM UNLEADED E] 4 GASAHOL E] 7 METHANOL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ iG MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br /> ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOY✓) <br /> D. IF(XI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING <br /> LINING OR ❑ 5 GLASS UNING UNLINED F--] 95 UNKNOWN ❑ 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE ITH 100% METHANOL? YES_ NO— <br /> D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F-� 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION ❑ 5 CATHODIC PROTECTION FSj�gl NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES_ NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES_ NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A&21 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A 671 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTIONIMER 1 MECL UNE LEAN 2 UTGIffKW 3 C W1111 S .4 4 ELEM MC UNE 5 AUTGM 110 PUMP <br /> ❑ GE NM=R ❑ TENE STING MOMTORING [EAI(DETECTOR ❑ SHIITpGWN E] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 RECO CIUATIONANUAL ORY ❑ 3 MONITORING VAOZE ❑ 4 GAUGINGAUTOMATMONITORING <br /> TANK E]5 MONITORINGGROUND TER ❑ 6 TESTINGTANK <br /> ❑ 7 CONTINUO US G INTERSTITIAL ❑ 9 SIR ❑ 9 WEEK LY MANUAL ❑10 MONT <br /> THLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br /> NG <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LA US (MO/DAY/YR) 2 ESTIMATED SUBSTANCE QUANREMATITY <br /> OF O GALLONS 3 WAS TANK FILLED INERMATERIAL 7H YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME DATE <br /> (PRINTED d SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE ILD:# m191c, <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TIWERGROUND STORAGE TANK REGULATIONS <br /> FORM B (6.95) <br />