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��yo�wcps STATE OF CALIFORNIA •"•+ STATE WATER RESOURCES CONTROL BOARD Wt mom+ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B nn •o�a,roww► COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. V MARK ONLY 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL O SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S [[ L ` / I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN !/ A OWNER'S TANK I.D.# B. MANUFACTURED BY: – C. DATE INSTALLED(MO/DAYNEAR) , D. TANK CAPACITY IN GALLONS: '� V UO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1c MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOVv) 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,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 ❑ i BARE STEEL ❑ 2 STAINLESS STEEL 3 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 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ ❑ ❑ LINING OR ❑ 5 GLASS LINING PRI-6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/o METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION � PROTECTION [:] j 5 CATHODIC PROTECTION Ell 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL et . SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) + cDROP 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 AO2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1001/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATH? IC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHWCAL UNE LEAK 2 LINE TK,HTNESS 3 CONTINUOUS INMRSTM& 4 ELECTROMC Ula 5 AUTOMATIC PUMP O ❑ OEIECfOR ❑ TESTING MOMTORING LEAK DETECTOR SHU WCN 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL ONCILIATIONORY ❑ 3 MONITORING 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑6 TESTINGTANK 7MON TOR CONTINUOUS ITERSTITIAL [—] 8 SIR ❑ 9 qNK GAUGING ❑10 MO TING TANK E–]NTHLY 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) L ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS B OW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m S J Qa_I g z a n b I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE p 2 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (695) 04�512410,