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• `��wt Ca STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �� I UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B •t�I IIOw N' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.11 B. MANUFACTURED BY: S C. DATE INSTALLED(MO/DAY/YEAR) �� D. TANK CAPACITY IN GALLONS: 'O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. \� 22 000 A. A21j 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY t PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tc MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE W ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.i 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 ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL tS3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE W/FRP (PHMa►YTanW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑'95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING r'2- UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? , ,• YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING , ❑ 3 VINYL WRAP ,J� 4 FIBERGLASS REINFORCED PLASTIC CORROSION 6` PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,6tC, SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES� NO STRIKER PLATE YES�_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE _ A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER' B. CONSTRUCTION A U i SINGLE WALL ACU 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 D4 FIBERGLASS PIPE 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 D. LEAK DETECTION E]' MEGUINCAL UNE lEAlt ❑2 LINE TrOMSS 3 CWUX)US WTERSTRIAL ELJ:CTRONC LINE 5 AurOMAnC PUMP ❑99 OTHER omc1oR TESTING MONTORNG EEIuL DETECTOR SHTMOWH V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL ORY ❑ 3 MAONNIITORING ❑ 4 GAGG AUTOMATIC TANK ❑5 MONITORINGROUND WATER ❑6 TTEESTINGNUAL TANK 7 CCOON INNUROU INTERSTITIAL ❑ 8 SIR ❑ 9 gNK GAUGING ❑10 TESNTITHHGY TANK E] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ 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 i SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER'S C MPOSED OF THE FOUR NUMB S BELO h-^ STATE LD:# COUNTY N JURISDICTION# FACILI TANKS 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 IS FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH jfERGROUND STORAGE TANK REGULATIONS FORM8 (B•95)