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w � STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD su - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B " o' COMPLETE A SEPARATE FORM FORE H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED p DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i� 3� �x., J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: L(�� C. DATE INSTALLED(MOIDAYHEAR) y��j D. TANK CAPACITY IN GALLONS: Oev G� II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL < OIL / C. 'UNLEADED REGULAR 8 3 DIESEL B AVIATION GAS ❑ 2 PETROLEUM C:] 90 EMPTY 1 PRODUCT ❑ tb PREMIUM 4 6ASANOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 09 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM rF 2 SMILE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATISLEWIFRP (PnmeryTwk) ❑ 8 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑^/2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR E:] 5 GLASS LINING L&, S UNLINED ❑ 05 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP I� 2 pOATINO ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ECTION ^LY PROTECTION Q 5 CATHODIC PROT9911 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTON EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 0 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ YONR AWGfTnAL ❑ 90 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK CADGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(MONDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO l 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 APPLICANTS NAME DATE IPBINTE9 a SK.IMTUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDA COUNTY# JURISDICTION# FACILITY# TANK* Ga;- � a b PERMIT NUMBER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FlLEp/D� l//`� FalomHue