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f7rr OunCl3 STATE OF CALIFORNIA r Pis`""„ STATE WATER RESOURCES CONTROL BOARD 3� • - <' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ` �. C1l IIOI�N�' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 2g 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' ( 111 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN ! A OWNER'S TANK I.D.# ,R B. MANUFACTURED BY: u �� t C. DATE INSTALLED(MO/DAY/YEAR) (�q 0. TANK CAPACITY IN GALLONS: ' jC>0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. I A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED 03 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El 1c MIDGRADE UNLEADED ❑ 5 JET FUEL F7 8 M85 ❑ ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM t ` 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 'i A. TYPE OF ❑ 1 DOUBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN C SYSTEM ❑ 2 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (h C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING '1❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIORF-1 1 POLYETHYLENE WRAP F—] 2 COATING F-1 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:195 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) I PIRILA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES '- NO STRIKER PLATE YES .` NO DISPENSER CONTAINMENT YES x:- NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE f A. SYSTEM TYPE A U I SUCTION A&2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A Z DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER L A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC)AU41 4 FIBERGLASS PIPE C. MATERIAL AND ( I. 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 lD. LEAK DETECTION f 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING MONITORING ❑ TEAK DETECTOR ❑£ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ / VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE O 4 AUTOMATIC TANK ❑ 5 GROUND WATER ❑ 6 ANNUALTANK ❑ 8 SIR ONCILIATION ❑ MONITORING ❑ GAUGING ❑ MONITORING ❑ TESTING 7 CONTINUOUS INTERSTITIAL 9 WEEKLY MANUAL 10 MONTHLY TANK 95 UNKNOWN 99 OTHER I, MONITORING TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NOE] 1`@ 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# T= 5 b 1,61 441 IV I ' PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I a THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC'AlON-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THElfGROUND STORAGE TANK REGULATIONS FORM B (6-95) FOR003413•R7 i�.