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tyovnces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Wl o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B p. _ . , o •C�LIfOR H.r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MART( 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: I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ,.�rw,,�r B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) [. vi a. D. TANK CAPACITY IN GALLONS: r H.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL F--j 4 OIL B. C 1a REGULAR UNLEADED a 3 DIESEL o 6 AVIATION GAS 2 PETROLEUM 7-180 EMPTY pKL 1 PRODUCT 1PREMIUM UNLEADED a 5 JET FUEL O METHANOL 1c c MIDGRADE UNLEADED 8 M85 ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 k-2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL a 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL /❑'5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/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 ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) �a E.SPILL AND OVERFILL,BIC. DROP TUBE YES NO STRIKER PLATE YES NO �S DISPENSER CONTAINMENT ES NO<>`a IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION �2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION !o 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION- 'W 1 MECHANICAL LINE LEAK �2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE [:]5 AUTOMATIC PUMP F 99 OTHER =C TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK D CTION 1 VISUAL CHECK MANUALRECONCILIATION INVENTORY 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK 5 MONITORING TER 8 TESTINGGROUND ANNUALTANK 7 CONTINUMONITOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKKLY GA MANUAL ❑10 MOTESTINGHL TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE ST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ � + SUBSTANCE REMAINING GALLONS INERT MATERIAL? tt 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 6kt (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ry 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 FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIfERGROUND STORAGE TANK REGULATIONS � ' /'►.r�� (J