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STATE OF CALIFORNIA r �, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 1:J8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: _ , <� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN T A. OWNER'S TANK I.D.# yam--- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: /1 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. l v A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ;gl 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS b PREMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED a 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,ANDALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH TERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS ST L ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL HLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVAN ED STEEL E] 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKY LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING El U�N INED F-195 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ COATING F73 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL 2tC. SPILL CONTAINMENT I ALLIED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE IF ABOVE GROUND OR 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 LL 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 EEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALU NUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 G VANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 ME CAL LINE LEAK 2 LINE TIGHTNESS 0 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP 99 GTHER D CTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTI ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING 3 VADOZE MONIITORING 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 6 ANNUALTESTING ❑ 7 MONITORING G IN RSTITIAL ❑ 8 SIR ❑ 9 TWEEKLY ANKGAUGING AL ❑ 10 TESTING E TINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSUF& INFORMATION(PERMANENT CLOSURE IN-PLACE) [7ESTIMATED DATE LAST USED(MO/DAYNR) 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 OWNER'S NAME DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Aec it 7 7 COUNTY# JURISDICTION# FACILITY# TANK# uU STATE I.D.'# 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 {��+ SH/1ODULD BE ACCOMPANIED BY A PLOT Pi"'r°IILE THIS FORM MWWITH �THE LOCAL AGENCY IMPLEMENTING THE I 9GROUND STORAGE TANK REGULATIONS FORT-�L I �� V i< 1� V Nor / r P i