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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO'WO; ]ALSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED �A+ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �JJ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: v ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. ��(( A. 4 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1iUNGGULARLEADEC 3 DIE SEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM a 80 EMPTY XL 1 PRODUCT ❑ lbPREMIUM _j 4 5 GASAHJET L ❑ ] METHANOL O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 7I„2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANKIBJ" 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL I'L�J 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdmuy Turk) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INFERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED �95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING a 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOICPROTECTION ❑ 91 NONE I'QT95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTKMI EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVENDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IFMA U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 9 CONCRETE A U 7 L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVAN12ED STEEL A U 10 CATHODIC PROTECTION J UNKNOWN A U 99 OTHER D. LEAK DETECTION gl AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNETIGHTNESS TESTING L MOufORUC ❑ g9 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK Tg 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS I INERTMATERIAL] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEDA 91GNAA PO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® 1 1/1 5T61/llil�I ;/ PERMIT NUMBER PERMIT APPROVED BV/OATE PERMIT EXPIRATION DATE I Z9 J THIS FORM MUST BE ACCOMPANIED BY A PERM57 APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED'.",� �J///J FILE THIS FORM WITH TMC LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS —/K FORM B (12-91)