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—� STATEOFCAUFORMA *af ONS STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION" FORM BCOMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REM DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) lL D. TANK CAPACITY IN GALLONS: 11.TANK CATENTS IFAI ISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. C• ❑ Ia REGUED 3 DIESELUNLEA ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 8o EMPTY (�21 ODUCT Ib PREMIUM 4 GASAHOL 7 METHANOL O UNLEADED 5 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN STE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOWI D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.0.S.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL = 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE I❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER I❑I 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C INTERIOR L! 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKN��O//�1QM�fN� � !�❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOJL�LI//�•• D.CORROSION ❑ I POLYETHYLENE WRAP ❑ COATING � 3 VINYL WRAP � 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE Q95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GRO DERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTIO A U 2 PRESSURE A U 3 GRAWry A U 99 OTTER B. CONSTRUCTION A U 1 SINGLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STE 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 STEEL W/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 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION OYI OY� ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 ROUND WATER MONITORING ❑ I TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER //— VI.TANK CLOSURE INFORMATION ` 1.ESTIMATED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 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 IPRINTEO a SIGNAMRhT LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 � p 31 T I PERMHTNUMBER PERMIT APPROVED SYIDATE- PERMITEXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGVLATIONS- `l/✓1/��=__� &R6