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NIA STRESOURCESC ON C;7 STATE'NATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM BCOMPLE E A SEPARATE FORM FOR EACH TANK SYSTEMA � MARK ONLY ❑ I NEW PERMrT ❑ 7 RENEWAL PERMIT �5 CH NF MATION ❑ 7 PERMANENTLY C}use0 ON SI�� ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT i - ❑ e TE TANK QSURE (1 S TANK REMOVED OSA OR FACILITY NAME WHERE TANK IS INSTALLED: L TANK DESCRIPTION COMPLETE ALL ITEMS— SPECT(IF UNKNOWN A. OWNER'S TANK L0.a 1 . MANUFACTURED BY. t/ C. DATE INSTALLED(MCIOAYA'EAR) ( L'I1 I 0. TANK CAPACITY IN CALLON& II.TANK CONTENTS IF4IISMARKEO.COMPLETEREMC. / A. Ty'I MOTOR VEHICLE FUEL a OIL B, C. ❑ I&REGULAs 2 OIESEL 8 AVIATION GAS GASANC ❑ 2 PETROL'eUM 9p EMPTY L 1 PROCUCT lb PREMUM a L 7 METHANOL S CHEMICALPROOUCT ❑ 95 UNKNOWN C32 WASTE ❑ 2 LEADED ❑ 5 JETFUEL ❑ 90 OTHER (DESCRIBE IN rtEM 0. SELCV.1 0. 5(At)IS v0T IMRKED. ENTER NAME OF SUBSTANC'c STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY W BOXES A B.ANO C.AND ALLTHATAPPLIES IN SOX A. TYPE OF ❑ I BLE WALL ❑ G SINGLE'NALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK (M-1 B.ARESTEEL ❑ 2 STAWLESS STEEL ❑ 0 FIBERGLASS ❑ a STEEL CLAC Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLCRICE ❑ 7 ALUMINUM B 100. METHANOL COMPATIBLE W/FRP (Primal Tank) ❑ 9 BRONZE ❑ 10 GALVAN¢D STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYO LNNG ❑ ] "EROX1' LINING ❑ a PHENOLIC UNWG UNWG ❑ 5 GLASS LNNG ❑ e UNLINED Cj,3 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ No O.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ ❑ 'NRAP C] a FIBERGLASS REINFORCED FUSTIC PROTECTION ❑ S CATHOOq PROTECTION ❑ 91 NCNE 95 VNKNOWIN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNCERGROUNO.BOTHIFAPPL:CABLE A. SYSTEM TYPE A(U I SUCTICN A U 2,PRESSURE A U 7 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A%U 2 DOUBLE WALL A U 0 LINED TRENCH A IJ 95 UNKNOWN A U 99 OTHER C. ATERIAL AND A V 1 BARE STEEL A U 2 STAWLESS s-EL A u 7 POIYYWYL CHLORIDE P �n ( MA U a FIBERGLASS PIPE CORROSION A V S ALUMINUM A U 9 CONCRETE A U 7 STEEL'N/COATJVG A V B 100% METHANOL CCMPA'.ISL=W/FRP PROTECTION A V 9 GALVANM STEEL A U 10 CATHCOIC PROTECTICN A U 95 UNKNOWN A U N OTHER 0. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK CETECTCR ❑ 2 LINE T GHTNESS TESTING ❑ I :V '+' UML 99 OTHER 4CNITCANG ❑ V.SANK LEAK DETECTION �IUAL ❑ 3 INVENTORY REGONCIIATX)N ❑ 2 VAPOR MONITCRWG❑ a AUTOMATIC TANK GAUGING❑ 5 GROUND WA ER MONITORING ❑ 7 NMPSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) I 2 ESTIMATED CUANTITY OF 1 WAS TANK FILLED WRN SUBSTANCE REMAINING GALLONS WERTYATEAIAL? YES ❑ NO❑ THIS FORM HAS SEEN COMPLEI-ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPUCANrS NAME INAIrNi(0 A fIGNANRq OATS LOCAL AGENCY USE ONL THE TE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS 8ECOW, Cc/'cam% . I COUNTY$ JURISDICTION 9 FACILITY• O TANK i J STAT 1.�1 l�Q p 2 p CI L�'T / PERMITNUMBER J� J I PERMIT APPROVED BY/DATE PER VF)PIRATIONOATE FORM B (9.9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM),_ ESS A CURRENT FORM A HAS BEEN FILED. FCaaG3aa