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STATEOFCAIFCRNA "`ee ..'ce. STATE WATER RESOURCES CONTROL BOARD g "� 'c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 'm� �la ry; COMPLETE A SEPARATE FORM FOR EA PH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 2 RENEWAL PERMIT ga'5 CHANGE OF INFORMATION a 7 PERMANENTLY CLO ITE ONE ITEM a 2 INTERIM PERMIT ❑ t AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE a 8 TANK REMOVED I / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: "` �fFO I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN FEEE TANK I.0.s B. MANUFACTURED BY: Cr,- K./n/5 C. DATE INSTALLED(MCIDAYYEAR) D. TANK CAPACITY IN GALLONS: 0 h-rrfl II.TANKC ENTS IFA-1 IS MARKED.COMPLETE ITEM C. V A. I MOTOR VEHICLE FUEL A OR S. tl AUNLEA ED REGULAR S DIESEL ❑ 8 AVIATION GAS I� A GASAHOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1eUN EMADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(AJ)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.a S.s III. TANK CONST—RUCTION MARK ONE ITEM ONLY IN BOXES A B.ANO C.AND ALL THAT APPLIES IN BCX0 A. TYPE OF DUSLE WALL ❑ S SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ a STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLMNYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100. METHANOL COMPATIBLE WIFRP (Prim9yTmk) ❑I 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ S EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LJ�C LINING 3 LINING MATERIAL COMPATIBLE WITH 100% METHANOL' YES_ NO_ D.CORROSION 711 POLYETHYLENE WRAP ��_ TING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Fk,91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEG NO OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 5 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I SAFE STEEL A U 2 STAINLESS STEEL A U 2 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANDED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS Tft<NG MOKROReMA. ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORING❑ l AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING e TANK TESTING ❑ ] INTERSTITIAL MONITORIN(9 ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER /// Vi.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAYNR) 2.ESTIMATED OUANTITY OF 0.WAS TANK FILLED WITH YES ❑ NO❑ 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 APPMTE0AN1LICTS NAMEREI DATE IPg91GMAN LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANK 9 STATE I.D.4 51 D b PERMITNUMBER PERMVAPPRQyED BY ATE PERMIT EXPIRATION GATE FORM B (390) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. l/�//F0R00a8A1