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P�gOUnC,9 CO <br />STATE OF CALIFORNIA P ti <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W <br />o�noaa`� <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ❑ 1 NEW PERMIT <br />❑ <br />3 RENEWAL PERMIT <br />❑ <br />5 CHANGE OF INFORMATION <br />❑ <br />7 PERMANENTLY CLOS D ON SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT <br />❑ <br />4 AMENDED PERMIT <br />❑ <br />6 TEMPORARY TANK CLOSURE <br />❑ <br />8 TANK REMOVED �. <br />V <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />Z G/Z v ` ; -17'4440, <br />❑ 7 ALUMINUM <br />24.-onr" <br />(Primary Tank) <br />❑ 9 BRONZE <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN I <br />A OWNER'S TANK L D. # �' , <br />B. MANUFACTURED <br />C. DATE INSTALLED (MO/DAY/YEAR) <br />D. TANK CAPACITY IN GALLONS:/ <br />II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />A. ❑''1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />Ea"i PRODUCT <br />1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br />❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />M, i DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. TANK <br />❑ 1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING OR <br />❑ 5 GLASS LINING <br />❑ 6 UNLINED <br />❑ 95 UNKNOWN <br />❑:°'-99 OTHER �yh T�fc <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO— <br />5 AUTOMATIC PUMP ❑ 99 OTHER <br />D. EXTERIOREl <br />1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />F--] 3 VINYL WRAP' <br />4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL BtC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A PRESSURE A U <br />3 GRAVITY <br />A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A DOUBLE WALL A U <br />3 LINED TRENCH <br />A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U 2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U 6 CONCRETE A U <br />7 STEEL W/ COATING <br />A U 8 100% METHANOL GIOMPATIBLE RP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />AAU 99 OTHER <br />D. LEAK DETECTION <br />❑a7 MECHANICAL UNE LEAK <br />❑ 2 UNE TIGHTNESS 3, CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC LINE <br />❑ <br />5 AUTOMATIC PUMP ❑ 99 OTHER <br />LJ <br />DETECTOR <br />TESTING ,, MONITORING <br />LEAK DETECTOq <br />SHUTDOWN <br />V. TANK LEAK DETECTION <br />ANNUAL <br />71 1 VISUAL CHECK ❑ 2 RECONCILMANUAL IATION NTORY ❑ 3 MONITORING F]VADOZE4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUNDWATER ❑ 6 TESTINGTANK <br />❑ 7 MONITORU INTERSTITIAL [:]8 SIR E:]9 TANK LY MANUAL ❑ 10 MO TINLY TANK El 95 UNKNOWN E::]99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT <br />TANK OWNER'S NAME DATE <br />(PRINTED S SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # <br />STATE I.D.4 FT -7 1 111p <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br />SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEWRGROUND STORAGE TANK REGULATIONS <br />FORM B (6-95) <br />