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8TATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM `'��o•�•' o MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION Q ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 7 PERMANENTLY CLO 917E ❑ ! TEMPORARY TANK CLOSURE a 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: UKP 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.i 2 B. MANUFACTURED BY: G C. DATE INSTALLED(MO(DAVHEAR) I S D. TANK CAPACITY IN GALLONS: 1 j ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. EK 1 MOTOR VEHICLE FUEL ❑ { OIL B. C. ❑ /iUREG AR NLEADEO 3 DIESEL ❑ 6 AVIATK)NGAS r72 PETROLEUM ❑ 60 EMPTY n 1 PRODUCT �1DPREMIUM 4 GAS'�L ❑ 7 METHANOL F-1CHEMICAL PRODUCT ❑ 95 UNKNOWN `•`❑ 2 WASTE ❑ 2 LNFLA�OED 5 JET FUEL 11 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B.ANDC,ANDALLTHATAPPLIESINBOXDANDE A TYPE OF yr 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM tn 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 96 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTX: MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (PLIm6ryTWt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C INTERIORLINING 5 GLASS LINING ❑ 6 UNLINED ❑ ❑ 99 OTHER 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YESX NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 1)571 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE ❑95 UNKNOWN W❑� 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A Lo PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A&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 6 CONCRETE A U 7 STEELMOOATING AQ B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 WE TMT- MON ❑99 OTHER V.TANK LEAK DETECTION F71 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING AUTOMATIC TANK GANGING ❑ 5 GROUND WATER MONITORING E] 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 05 UNKNOWN ❑ 90 OTHER A TANK CLOSURE INFORMATION 1.ESTIMATED ST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTaS,gNwA7yMnE� 'r � / (A+ � � -y� � / �9 1gBLrrt[ r T'fiFL`.C? I o� DAA-A \ A+-Is L-R-k .F�p, DATY__Z S LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 6 COUNTY# JURISDICTION# FACILITY# TANK# 00 STATE I.D.# m = m L_L�LI rT D 6 / PERMITNUMBER a3 I E PERMIT APPROVED BY,DATE L-- _PLER-JMIT EXPIRATgN DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (1291) FILE THIS FORM WITH THE I^CAL AGENCY IMPLEMENTING THE UNDERGROUND STORA^c TANK REGULATIONS - `v 1-w FON00116AF