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RNIA STATE WATER RESOSTATE OURCES CON TROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B r, 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. [�MAAK ONLYO 1 NEW PERMIT 3 RENEWAL PERMIT ❑E ITEM 2 INTERIM PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONSITE 4 AMENDEO PERMIT ❑ 8 TEMPORARY TANK CLOSURE 0 B TANK REMOVED Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c» S. I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNER'S TANK I.D. Q/ MANUFACTURED BY: C. DATE IN57ALLED(MO/Ogy/YEAq) L[l =oE u EEEEED].=TANKCAPACITY IN GALLONS: II.TANKCO ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ la REGULAR R 3 DIESEL 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib P�E MIDM 4 GASAHOL ❑ 7 CHEMICAL PRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE ,^ ,UNLEAOED ❑ 5 JETFUEL ❑ 7 METHANOL LTJ 2 LEADED O yg OTHER (pE$CgIBE IN ITEM D. BELOW) O. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLIES IN BOK D AND A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERK)q LINER fL—Jy ❑ 95 UNKNOWN SYSTEM 2 SI LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank( ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN '❑ 99 OTHER ❑ 1 RUBBER LINED 2 D LINING C.IINTERIOR ❑ ALKY ❑ 3 EPDXY LINING � 4 PHENOLIC LINING LINING ❑ 5 SSS LINING �NLWED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%MET14ANOL7 YES— NO— D.CORROSION O_D.CORROSON ❑ I POLYETHYLENE WRAP = 2 TING ❑ 3 VINYL WRAP ❑ 6 FIBERGLASS REINFORCED PLASTICPROTECTION ❑ 5 CATHODICPROTECTIOJ 91 NONE 095 UNKNOWN 0 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUN IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A :1 PRE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U' A V 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELWICOATING 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 0 2 LINE TIGHTNESS TESTING 11MONITORING CD 99 OTHER V.TANK LEAK DETECTION ggUUT7pp ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOg MONITORING 0 t MATIC TANK GAUGING 0 5 GROUND WATER MONITORING 0' 8 TANK TESTING 0 7 INTERSTITIAL MONITORING ❑ 91 NONE 1�—, '96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USE ( WYq) 2.ESTIMATED QUANTITY OF 3 7/ SUBSTANCE REMAINING _ 3.WAS TANK FILLED WITH YES ❑ NO 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 IPmI o a SIGMA AE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY 9 JURISDICTION 9 FACILITY s TANK i CT 201 3 9 s PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �FIX1amIB-q5 E