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i r ♦ " I BTATEOFCAUFDRwa 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 OF INFORMATION PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT d AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I!� + E_ .96PG'�Af4'o I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# D'` B. MANUFACTURED BY: C040eel/_V/) C. DATE INSTALLED(MO/DAY/YEAR) -q-7 D. TANK CAPACITY IN GALLONS: P�� ILTANKCONTENTS IF AG IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. �" R 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY UNLEAD PRODUCT ❑ Ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 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 #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ,❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM r2 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F–] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINEDKVD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 CLASS LINING 8 UNLINED ❑ 95 UNKNOWN E:] 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAPn 2�COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION;I f 991 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 02 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL rU 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 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 PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STE W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING E:1 71NTERSTI W MONITORING 99 OTHER _ E:] V.TANK LEAK DETECTION ❑ 1 ISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE VST U D MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME PATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# / � f STATE 04 = �� D PERMITNUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE -r FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 7 FOROOM881