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71 �(: � tyouAces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W�' a "r •CSL IROF H�' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a K. 5to p I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# r V i"1 B. MANUFACTURED BY: G. 1 'jQ C. DATE INSTALLED(MO/DAYNEAR) { D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. r A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. /d la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E:] 80 EMPTY 1 PRODUCT El 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 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 V2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 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 I C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING V UNLINED E:]UNLINED F_] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESIc. NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGV91 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION f PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE UNKNOWN ❑ 99 OTHER 1 01 F2 A I SPILL CONTAINMENTNSTALLED(YEAR) OVERF,$VPREVENTION EQUIPMENT INSTALLED(YEAR)rl' Ln r E.SPILL AND OVERFILL,etc. DROP TUBE YES 'i� NO TIER PLATE YES NO DISPENSER CONTAINMENT YES NO Aff- IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE l A. SYSTEM TYPE A U 1 SUCTION A4 0 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER I B. CONSTRUCTION U ,i1 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 S L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U ,9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER E D. LEAK DETECTION r" 1 MECHANICAL LINE LEAK t 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP i DETECTOR ® TESTING MONITORING LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER I� V.TANK LEAK DETECTION oe [ ;: ❑ 1 VISUAL CHECK RECONCILIATIONMANUAL ORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 6 TESTINGTANK ` ❑ 7 CONTINUOUS INTERSTITIAL V SIR ❑ 9 TANEK GAUGING TESTING❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 'i I 1.ESTIMATED DATE LAST USE(D,(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO lklCb F";', SUBSTANCE REMAINING GALLONS INERT Mt!l ATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY F ARJUY4ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED b SIGNATURE) {\ n ( � LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IOM\POSEDWHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl mFTTI 11 1 1 Ill 1011111110111 PERMIT NUMBER PERMIT APPROVED BY/DATE 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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U ERGROUND STORAGE TANK REGULATIONS FORM B (6-95) R ` c