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♦Fy n.ur �o STATEOFCAUFORMA i iSTATE WATER RESOURCES CONTROL BOARD iUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B o I y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSOE ONE REM ❑ 2 INTERIM PERMIT 4 AMEND PERMIT ❑��75 TEMPORARY TANK CLOSURE ❑�^ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G.S /7 I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN iA OWNERS TANK I.D.t B. MANUFACTURED 8Y: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A<1 MOTOR VEHICLE FUEL ❑ 4 OIL B.�/ C. ❑ taUNLEA ED REGULAR e 3 DIESEL ❑ g AVIATION GAS I ❑ 2 PETROLEUM ❑ w EMPTY 71�1 PRODUCT ❑ 16 PREMIUM 4 ��L ❑ 7 METHANOL T 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.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER I �1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS Q 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE Q 7 ALUMINUM Q 8 100% METHANOL COMPATIBLE W/FRP (PdmtryTAnt) ❑ 9 BRONZE Q 10 GALVANIZED STEEL Q 95 UNKNOWN ❑ 99 OTHER Q 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING �8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING /X IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES- NO_ D.CORROSION Q / POLYETHYLENE WRAP Q 2 COATING ❑ 3 VINYL WRAP C:] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION1 NONE ❑95 UNKNOWN ❑ 9e OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 95 UNW40WN 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 ST L WI COATING A U 8 100% METHANOL COMPATIBLEWFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U w OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ ZI MONITORING 9B OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION Q 3 VADOZE MONITORING Q 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING Q 7 INTERSTITIAL MONITORING X91 NONE Q 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION ra. L ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUB STA NCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED Ill SIGNATIIRID LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW c COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# FIR �7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITHSMF LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1 FORME (12-91) ��IIJL � / / I✓" '�� FOROmms