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t5°URCl3 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD W <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />• CSI II°R R,� <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLYi NEW PERMIT 03 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION <br />[:] <br />7 PERMANENTLY CLOSED ON SIT <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT <br />❑ 6 TEMPORARY TANK CLOSURE <br />0 <br />8 TANK REMOVED p� / <br />C/ <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED:" <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 />0 6 POLYVINYL CHLORIDE 0 7 ALUMINUM <br />I. I ANK UtbL;Hll' I IUN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # <br />B. <br />1 PRODUCT <br />2 WASTE <br />B. MANUFACTURED BY: <br />C. DATE INSTALLED(MO/DAYNEAR) <br />-�� -R.n <br />D. TANK CAPACITY IN GALLONS: <br />dF <br />II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />A. -V 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />4lyF '— 1 BO EMPTY <br />2 PETROLEUM ❑ <br />02 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />B. <br />1 PRODUCT <br />2 WASTE <br />C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />`1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />El 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <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 />"'1' 1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN <br />SYSTEM <br />LJ 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 />0 6 POLYVINYL CHLORIDE 0 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />0 10 GALVANIZED STEEL <br />0 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />O 1 RUBBER LINED <br />0 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 <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES NO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP 0 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />IK <br />CORROSION <br />PROTECTION <br />5 CATHODIC PROTECTION ❑ 91 NONE <br />❑ 95 UNKNOWN <br />99 OTHER <br />i � � _ff — I <br />SPILL CONTAINMENT INSTALLED (YEAR) <br />E. SPILL AND OVERFILL, EtC. DROP TUBE YES NO BIKE 7LATE <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />YES 4 '' NO DISPENSER CONTAINMENT YE 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& 2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A 02 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A 2 STAINLESS STEEL A U <br />A U 6 CONCRETE A U <br />A U 10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)Ar` U+; 4 FIBERGLASS PIPE <br />7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br />A U 95 UNKNOWN A U 99 OTHER <br />D. LEAK DETECTION <br />❑ <br />1 MECHANICAL UNE LEAK 1:12 <br />DETECTOR <br />UNE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL 0 4 ELECTRONIC UNE <br />TESTING MONITORING LEAK DETECTOR <br />5 AUTOMATIC PUMP 0 99 OTHER <br />SHUTDOWN <br />V. TANK LEAK DETECTION <br />MANUAL r�ANNUAL <br />❑l 1 VISUAL CHECK 0 2 RECONCILIIATIONVENTORY ❑ 3 MONITORING O VADOZE4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 8 TESTINGTANK <br />7 CON TORINWORN INTERSTITIAL E:]8 SIR 0 9 TANK WEEKLY <br />MANUAL ❑ 10 MO TIHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br />VI. TA K CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) V.4 <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) I 2. ESTIMATED <br />SUBSTANCE QUANTITY <br />OF GALLONS I 3. WASNERT TANK FILLEDMATERWII7H YES 0 NO REMA❑ <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 />(PRINTED6 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:# <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />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 <br />FORM B (6-95)SHOULDCOMPAN+IE � A PL � FILE FORM THIS THE LOCAL AGENCY IMPLEMENTING T�DERGROUND STORAGE TANK REGULATIONS <br />