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tlt� C t STATE OF CpUFMA +p STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B , oa COMPLETE A SEPARATE FORM FOR EAC K 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��TLLANK CLOSURE ❑ B TANK REMOVED Ory DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Fi Ul G-'RO I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN „rY t B. MANUFACTURED BY: A. OWNER'S TANK I.O.s V o` C. DATE INSTALLED(MOI'DAV/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCO NTS IFA-11S MARKED,OOMPLETE ITEM C. a REGULAR O 3 DIESEL ❑ 6 AVIATION GAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O UNLEADED ❑ 4 GASAHOL A 2 PETROLEUM ❑ 00 EMPTUM Y 1 PRODUCT ❑ 1bUN UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ g9 OTHER (DESCRIBE IN ITEM D. BELOW D. 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 ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 BLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 2GL SYSTEM E WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ER(1 BARE STEEL E] 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE [:] 6 POLYVINYL CHLORIDE [:] 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP MATERIAL E] (PfimuYTu9c) ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? VE8_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLEA IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCT A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9 KNO A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MpEK5111 L [:]99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTPMKrrCTANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE NE9UNNNOW � ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U ( O/D V/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING — GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PW NTED 6 SIGNAN LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE COUNTY# JURISDICTION# FACILITY# TANK# ff! STATE I.D.# ® 5 PERMIT NUMBER PERMITAPPROVEDBY/DATE P ITEXPIRATIONDATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORO0 B N 6�