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SrATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD •...� a � o UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°•"'� MARK ONLY 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 0/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I S7%Ly fl I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNERS TANK LD.i y B. MANUFACTURED BY: C C. DATE INSTALLED(MOIDAVHEAR) I D. TANK CAPACITY IN GALLONS: D �D II.TANK ENTS IFA-11SMARKED,COMPLETE ITEM C. A. L 1 MOTOR VEHICLE FUEL ❑ A OR B. C• ❑ 1iUNLEADGR ED 0 DIESEL ❑ 8 AVWTIGN GAS F72 PETROLEUM ❑ SO EMPTY 1 PROOUCT IOPREMIUM A GASAHOL ] METHANOL UNLEADED ❑ 5 JETFUEL ❑ S CHEMICAL PRODUCT Q 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ N OTHER (DESCRIBE IN ITEM 0. BELOW) 0. 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 S.AND C,AND ALL THAT APPLIES IN BOX DOUBLE WALL — 0 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ L— ❑ 95 UNKNOWN SYSTEM 2 GLE WALL a SECONDARY CONTAINMENT (VAULTED TANK) ❑ N OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL C:] 0 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑I f0 GALVANIZED STEEL ❑11 95 UNKNOWN ❑ W OTHER ❑ I RUBBER LINED ❑ 2 0 LINING ❑ 0 EPDXY LINING a PHENOLIC/LIININNGG C.INTERIOR ^I 5 GLASS LINING 8 UNLINED ❑ A5 UNKNOWN N OTHER (/ /� LINING LJ I❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP COATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION LZ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA80VEG NOOK U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PgESSURE A U 9 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A V 2 DOUBLE WALL A U 0 LINED TRENCH A(U_)M UNKNOWN A U W OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL WI COATING A U 9 100% METHANOL COMPATIBLE WIFRP PROTECTION A u 9 GALVANIZED STEEL a u 10 CATHODIC PROTECTION A/D 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MOKROPNG ❑90 OTHER V.TANK LEAK DETECTION IK� I�NANN TESTING ❑ 7 INiERSSUAL CHECK 11312 ORY TITIAL MONITORIING N ❑ 91VAPOR NONEMONITORINGO 95 AUTOMATIC UNKNOWN TANK GAUGING a NGOTHER WATER MONITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OLIANTRY OF 0•WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (V W NTEO a SKd1ATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY IT TANK it STATE L ,#h ® p PERMITNUMBER I ILA PEPMPPROVED=V ATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. _y •_ .. / POMm19M