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`-� STATE OFCAUFORMA ' STATE WATER RESOURCES CONTROL BOARD sf UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B W � ': Y/ p rJ• . COMPLETE A SEPARATE FORM FOR:2 TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: s I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# S. MANUFACTURED BY: LJtr-- C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: /0, Do J II.TANK COtPTNTS IFA-1 IS MARKED.COMPLETE ITEM C. i MOTOR VEHICLE FUEL ❑ 6 OIL B. / O ❑ 1aUNLEADED REGULAR3 DIESEL ❑ 6 AVIATION GAS A. 1Lol( GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 19UPREMIUM N LEADD 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ® 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.t)IS NOT MARKD. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.ANDALLTHAT APPLIES INBOX D AND A. TYPE OF ❑ i BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM CZ2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER I BARE STEEL ❑ 2 STAINLESS STEEL F-13 FIBERGLASS E] a STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 �� ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PdmryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERCR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 TING F73 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION EDECTKXJ 9/ NOS CATHODIC PROTNE ❑95 UNKNOWN ❑ W OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A FABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AOZZIS SSUR A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 5 L 'WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U BAR ST A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONROR9IG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAD02E- MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONITORING 91 NONE ❑ 95 UNKNOWN ❑ 09 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED"ANTITV OF 3.WAS TANK FILLED WITH YES NO SU ST GALLONS INERT MATERIAL ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE I'RIHTfD 8 61GHATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ,S/E ip S Jib STATE LDA 3 CI �m ! 0 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION DAZE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BE�( FOFMMB415