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• , =a1 .. • e PtgOURC,'9 C 1' STATE OF CALIFORNIA .P oti STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •C1t IfpR R� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFYJ•F UNKNOWN A OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 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 ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN v ` WASTE ❑ 2 LEADED [_] 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED `IW � ' C.A.S.#: Q 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 F—] 2 STAINLESS STEEL F—] 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 C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑_5 GLASS LINING ❑ 6 UNLINED Sir 95 UNKNOWN ❑ 99 OTHER i COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? "'YES— 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 SPILL CONTAINMENT INSTALLED(YEAR) fM OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,OtC. DROP TUBE YES NO jt _ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE I A. SYSTEM TYPE A U t SUCTION A U 2 PRESSURE A 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AhU,;(t 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 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 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 LINE LEAK ❑2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ANNUAL El t VISUAL CHECK ❑ 2 MANUAL INVENTRECONCILIATIONORY ❑ 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK [:j5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK ❑ 7 MON TORWG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL E]10 MOST HLY TANK ❑"95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY R 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO .- y 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Q C, , COUNTY# JURISDICTION# FACILITY# - TANK# STATE I.D.4 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRA 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 PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95)