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s _ STATE OF CALIFORNIA .P oti ^^ � STATE WATER RESOURCES CONTROL BOARD ; g 1 ` V 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 TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I `( I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# N(� �/ �4//� B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) !� /C D. TANK CAPACITY IN GALLONS: . II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. (� A. 54L 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑:1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ,1 PRODUCT FZ;or 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM O.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. ig 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 X- 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 y ❑ 99 OTHER F—] ❑ B. TANK 1 BARE STEEL 2 STAINLESS STEEL p 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F75 CONCRETE El POLYVINYL CHLORIDE f LT«❑— 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 ❑ 9955/UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES d NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,Etc. SPILL CONTAINMENT INSTALLED(YEAR) f OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A6�A 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) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK ❑2 UNE TIGHTNESS CONTINUOUS INTERSTITIAL O 4 ELECTRONIC UNE AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZEMONIITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER ❑ 6 TETANK STING 7 CONTINUOUS INTERSTITIAL 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MONTHLY TANK E::] 95 UNKNOWN ❑ 99 OTHER MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETEQ UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME / DATER (PRINTED&SIGNATURE) I l � 7 �/ LOCAL AGENCY USE nNW THE STATE I.D.NUM r IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# I e TANK# STATE I.D.# m ❑m 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 SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6.95)