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STATEOFCAUPORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACHTW YSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 O "41 W I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.A Q B. MANUFACTURED BY: 4(1(-- C. DATE INSTALLEO(MOIDAYHEAR) D. TANK CAPACITY IN GALLONS: SUV �7 II.TANK CO NTS IFA-11SMARKED.COMPLETEITEM C. C A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ le REGULAR ED 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY / PRODUCT 10 PREMIUM 4 GASA140L 7 METHANOL ❑ UNLEADED 5 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) O. 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 A. TYPE OF ❑ OOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 �LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ % OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVNIZED STEEL ❑ 95 UNIWOWN ❑ % OTHER ❑ / RUBBER LINED " ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. ININGR ❑ 5 GLASS LINING 8 UNLINED ❑ % UNKNOWN ❑ % OTHER IS LINING MATERIAL COMPATIBLE WITH /0D%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ % OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLKABLE A. SYSTEM TYPE A U I SUCTION A PRES E A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WA A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % 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 E CORROSION A U 5 ALUMINUM p U a CONCRETE A U 7 STEEL W/COATING A U 8 100% M ANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U % O D. LEAK DETECTION ❑ I AUTOMATIC LI EAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 % OTHER P MONITORING v ? ` 'C- -V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATON ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ % OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED( Y 2.ESTIMATED WANTRV OF 3.WAS TANK FILLED WITH Z SUBSTANCE REMAINING D GALLONS INERT MATERIAL? YES ❑ :NOE. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRNTED 4 91GNN%M LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION# FACILITY# TANK• STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORD &Rl