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STATEOFCAUPORNA ` STATE WATER RESOURCES CONTROL BOARD + 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 CF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r?j'zj g 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNER'S TANK I.D.f B. MANUFACTURED BY: V C. DATE INSTALLED(MdDAYNEAR) U, K , 0. TANK CAPACITY IN GALLONS: p ILTANKCONTENTS IFA,I ISMARKED.COMPLETErTEMC. MOTOR VEHICLE FUEL ❑ 4 OIL 8. C ❑ 1A��D 3 DIESEL ❑ 5 AVIATKNGAS A ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT 1E PREMXIM 4 GASAFIOL ❑ 7 METHANOL ❑ UNLEADED ® 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED W OTHER (DESCRIBE N ITEM O.BELOW) D. IF(0.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A•S.a III. TANK CONSTRUCTION MARKONEITEAIONLVINBO)(ES0.8,ANDC,ANDALLTHATAPPLIES N BOX A.TYPE OF QUI DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM t�2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER t BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (PrimaryTank) ❑ 9 BRONZE ❑ f0 GALVANDSD STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LNNG En a UNLINED ❑ 96 UNKNOWN ❑ N OTHER LINING IB LINING MATERNL COMPATIBLE WITH toox METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATWO ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION❑ 91 NONE 96 UNKNOWN ❑ 99 OTHER N.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A© 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNSOWN A U 99 OTHER C. MATERIAL AND Aq I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U a CONCRETE A U 7 STEEL W COATING A U S 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 LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 5 MONITORING ❑W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING �-,S�'TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNW40WN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYHR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FED WITH YES ❑ ❑ 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 IP.. DATE IppxTE9 i 31GNATURE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY f JURISDICTION f FACILITY 9 TANK It STATE I.D.# I 1 116 1 1 1 1 ` aIj PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE F•? 4 FORM 8 (11,9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. IdM6N8M, 1 ��