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STATE OF CALIFORNIA Ar ° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - C'I IIORN' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL LOSE SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: ❑ 2 STAINLESS STEEL � 3 FIBERGLASS I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # B. MANUFACTURED BY: li4z� C. DATE INSTALLED (MO/DAYNEAR) I vt $, D. TANK CAPACITY IN GALLONS: jQ (w 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 80 EMPTY El PETROLEUM F–]1. 1 PRODUCT PREMIUM UNLEADED ❑ 4 L ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 JET FUEL ❑ 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 MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF LTJ 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 ❑ 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 C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Vs 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D°k 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 CONTAINMENI1 STALLED (YEAR) 1 w E. SPILL AND OVERFILL, BSC. OVERF REVENTION EQUIPMENT INSTALLED (YEAR) NO DROP TUBE YES _ NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES IV- PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A V4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL UNE LEAK DETECTOR ❑ 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTMAL 4 ELECTRONIC LINE TESTING ® MONITORING LEAK DETECTOR 5 AUTOMATIC PUMP ❑ 99 OTHER SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECKLSI 2 RECONCILMANUAL IATIONENTORY ❑ 3 MONITORING � 4 GAUG NGIC TANK AUTOMAT❑ 5 MONTORINGTER GROUND ❑ 6 TESTINGANNUAL 7 MONITORCONTINUOUS ❑ 8 SIR ❑ 9 WENK LY M GAUGING ❑ 10 MONTHLY TING TANK [:]95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THI, FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AN9 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND GOR TANK OWNER'S NAME DATES [PRINTED d SIGNATURE) I nl A 1 Ar=Mf'V I IQ= n1V1 V Tuc QTATC I n FJI IMRPR IS CnMPnSiR11 nF THF Fn11R NIIMRFRS RFLOW _CT 1.014TANK STATE I. COUNTY # JURISDICTION # # FACILITY# Uon C ( l `l PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL- FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. � MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95)