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STATEOFCAUFORWA STATE WATER RESOURCES CONTROL BOARD y o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rat COMPLETE A SEPARATE FORM FOR EAC#TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT /❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /(/o9 Cl c.-�� 4-9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# D / B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: 0 II.TANK EMS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ d OIL g, C. ❑ 1aUNLE DED 3 DIESEL ❑ e AVIATION GAS d GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1E NLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 LE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ W OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑l� 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED KYD LNING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C. LINING INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ gg OTHER IS LINING MATERIAL COMPATIBLE WITH 10-0`%METHANOL? YES_ NO_ D.CORROSION F71 POLYETHYLENE WRAP TING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED"PGIBTIC_,_ PROTECTION ❑ 5 CATHODIC PACT; CTK)N 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U TKTN A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U INGL WA A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U paMMg5L> A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORNG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VA002E MONITORING ❑ d AUTOMATK:TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USM Y/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (MW D8SIGMU RET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER B COMPOSED OF THE FOUR NUMBERS BELOW COUNTY It JURISDICTION# FACILITY# TANK• 5"TFFA /Ij STATE I.D.# 7 �m 0151 (7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (/-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOROmIBAS