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STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD o ' 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 CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED '� a9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L,o� -'` 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# 7. 13. MANUFACTURED BY: L. C. DATE INSTALLED(MOIDAYNEAR) r- O. TANK CAPACITY IN GALLONS: f2- 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- 1 MOTOR VEHICLE FUEL a 4 OIL B. C ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED GASAHOL ❑ 7 METHANOL ❑ 1c MIDGHADE UNLEADED a 5 JET FUEL ❑ B MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ WASTE ❑ 2 LEADED ❑ 99 OTHER(OFSCRSE IN REM 0.BEI OW) D, IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# 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 171 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER "`YTt��"'' B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ^❑A3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? S_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP 4 FtSERGLASS REINFORCED PLASTIC CORROSION E.PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER SPILL AND OVERFILL,ELC SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE 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 U 1 SINGLE WALL A U Z' DOUBLE WALL A U 3 LINED TRENCH A02 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 7STE /COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]1 MEOU 1 UNE LEAK �2 UNE TIGHTNESS F7OMINU 3 cWS INTERsTmAL �4 ELECTRONIC UNE �5 AUTOMATIC PUMi DETECTOR ❑ 99 OTHER TESTING MIONRORING LEM DETECTOR 91UTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATIONIORY ❑ 3 MON ORING ❑OZE 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGOUND �R TESTINGTANK ❑ 7 MON TQR NG INTERSTITIAL ❑ B SIR ❑ 9 WEETANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN �99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ` 1.ESTIMATED DATE LA USE M Y�YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑r 0,$rSUBSTANCE 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 STATE 104COUNTY# JURISDICTION# FACILITY# TANK# L 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. FOR OUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN.THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNI ROUND STORAGE TANK REGULATIONS FORMS (6-95)