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� F . � PESOUnCtS O STATE OF CALIFORNIA .P ° STATE WATER RESOURCES CONTROL BOARD W _ m v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( i •0�41I On N\� 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 0 -1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' ,. C J e 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: 104 6�67 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL F74 OIL B. C ❑ 1a REGULAR UNLEADED ?�3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ tb PREMIUM UNLEADED4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 H 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION RK 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 F-14 SINGLE WALL IN A VAULT El99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ED FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 1 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 AL LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLIN ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% MET NOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION EE] 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKE PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UND RGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 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 U 1 BARE STEEL A U 2 STAINLESS STEEL A3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS [--13❑TNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR ❑ TESTING MONITORING LEAK DETECTOR [:] SHUTDOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ECONCILI TIIONMANUAL INVENTORY F-] 3 MONITORING VADOZE ❑ 4 AUTON GAUGIN TIC TANK ❑5 GROUND WAMON TORINGTER ❑ 6 TESTINGANNUAL❑ 7 CONTINUOUSMONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANKGAUGAG WEKLY INAL ❑ 10 MO TINGY NK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) �-�T 1.ESTIMAT D DATE ST SED( /D YNR) 2.ESTIMATED QUANTITY OF 0 3.WAS TANK FILLED WITH YES ❑ NO lyC I SUBSTANCE REMAINING GALLONS INERT MATERIAL? y`� 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 BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 Q❑ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE NZ I ja7 117 :1 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 INSTA LATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P18FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE f RGROUND STORAGE TANK REGULATIONS �p� FORM B (6-95)