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• nib G✓ T`�i✓� �"�?r�',,,�,�s� STATE OF CALIFORNIA w`�•• oo' STATE WATER RESOURCES CONTROL BOARD iy UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •o�irrow..r� 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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C Ty I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.K B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) e'C D. TANK CAPACITY IN GALLONS: ,i II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B_ C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS El2 PETROLEUM ❑ 80 EMPTY PRODUCT] ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ©<c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED a 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.I: [�C�C✓ 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 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 E73 EPDXY LINING E] 4 PHENOLIC LINING I - 6 LINING OR ❑ 5 GLASS LINING UNLINED ❑ '95 UNKNOWN ❑ 99 OTHER 5U COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES v 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) OVERFILL PRPENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES ✓ NO STRIKER PLATE YES 4/ 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 A6/2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACU-)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 6;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 U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWNA U 99 OTHER D. LEAK DETECTION MECHANICAL UNE LEAK 2 UNE TIGHTNESS of CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE M 5 AUTOMATIC PUMP ❑ DETECTOR TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ,I❑ 11 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORY E] 3 VADOZE MONITOR ❑ 4 GAUGING IC TANK [:] 5 GROUND MONITORING TER ❑ 6 TESTINGTANK 7 CONTINUOUS MONITORING INTERSTITIAL � SIR ❑ 9 TANEKLY KGAUGING AL E] 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TESTVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ,// /1 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF' 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF JURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ` DATE (PRINTED 6 SIGNATURES LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS CqwoSED OF THE FOUR WI#BERS BELOW �s COUNTY 8 JURISDICTION N FACILITY k TANK k STATE I.Dl m 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 PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)