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f. STATEOFCAUFCFNA ^s`�"r• _ �J STATE WATER RESOURCES CONTROL BOARDy *� / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B = aIo i o I COMPLETE A SEPARATE FORM FOR E H TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGrl �E OF INFORMATION ❑ NTLY C N ITE �� 7.PERMAN/ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 0 TEMPORARY TANK CLOSURE E S TANK R MOVE ^ OBA OR FACILITY NAME WHER N S INSTALLED: I. S 3 a 1. TANK OESCRIPTION COMPLE4 ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.0 1 B. MANUFACTURED BY: Ifj C. OATS INSTALLED IMOIOAY AR) 0. TAW TANK CAPACITY IN GALLONS: �� I 11.TANK C EMS IFA.IISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ t OIL B, C o to REGULAR 3 DIESEL ❑ g AVIATION G AS �l UNLEADED 4 OL ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT ❑ i4 NLEADED S�SETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROOUC7 ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.SELOvr) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C_A.S.i 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ T DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 10�2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC I MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 MINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ y gpONZE ❑ t0 GALVANRED STEELcl 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINEO ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F75 GLASS LINING ❑ 6 UNLINED 95 UNOWN ❑ 94 OTHER i IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO..,_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ! PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER r 1V.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IFUNCERGROUND.BOTHIFAPPLICABL$ A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U T 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 STEEI. A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE ' CORROSION A U S ALUMINUM A U E CONCRETE A U 7 STEELWICOATING A U I! S00% METHANOL CphApgT18L5 WiFAP I PROTECTION A U 9 GALVANCED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER O. LEAK OETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING3MCWL C]❑ HITOPoND 99 OTHERy V.TANK LEAK DETECTION fj I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITCRING i ❑ 5 TANK Tama ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNQ4CWN ❑ 99 OTHER V1.TANK CLOSURE INFORMATION II ESTIMATED DATE LAST USED(MOrDAY/YR) 2.ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH 1 SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT t APPLICANTS NAME IPR'INTEO•SLGNATVRE) DATE LOCAL AGENCY USE ONLY��,THHE/�STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW { STATE I. ,'� (/✓/rc " OUNTY 0 JURISDICTION 9 FACILITY x TANK N ' 37 P1;RMlT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION ATE i FORM B (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FOROG31 I