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STATE O STATE WATER RESOURCESURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B id+ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SI ONE ITE ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA 0 AC ITY NAME WHERE TANK IS INSTALLED:HQ�J .� U,�j,�{, I. T K ESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN I A R'S TANK I.D.x B. MANUFACTURED BY: VIM INSTALLED(MOIDAV/YEAR) D. TANK CAPACITY XJ GALLONS: II. ANKCONTENTS IFA-11SMARKED,COMPLETE REM C. to REGULAR 3 DIESEL ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bPREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 52r 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 41t&44W Ar7- 2_I C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL HAT APPLIES IN BOX D AND A. TYPE OF ❑I�1 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXT IOR LINER ❑ 95 UNKNOWN SYSTEM [59L 2 SINGLE WALL ❑ 4 SECONDARY CONTAIN ENT (VAULTED TANK) ❑ 99,OTHER B. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASSREINFORCEDPLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHILD F__] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmaryTank) E] 9 BRONZE ❑ 10 GALVANIZED S EL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LININ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED li4 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% ME OL7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATIN ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NON Ix 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YE ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGRO DOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A ri SUCTION A U 2 PRESSURE p U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM U 6 CONCRETE A U 7 STEEL W/COATING 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 D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEA DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING x 99 OTHEfl V.TANK LEAK DETECTION x1 VISUAL CHECK ❑ 2INVENTORY R NCILIATION [:] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING F-16 TANK TESTING F-] 7 INTERSTITIAL ONITORING F-191 NONE E] 95 UNKNOWN C:399 OTHER I. N L UR FO A N T T LA U DMO A N 2.E IMAT O A I 3.W S T KFI ED WI E NO BSTA E EM ONS INE T TERIWI HIS O HA BEE CO LET DUN ERP NALTY oy PE JURY,AND TO THE BEST OFVY KIVOKII EDGE, IS TRUE AND CORRECT APPLICANTS NAME -.Fyf�11(I I` 1 DATE (PRINTED a SIGNMRE) "„J` I {� Iz—i (/f LOCAL AGENCY USE ONLY ''THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUU,M'B'ERS BELOW 14/ COUNTY# JURISDICTIO # -FA67l1T-YTANK# ' VSTATE I.D.# L—L"6G_MIT]acr-3.1/y PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B V-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROBN 1 ' ��N,