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STATEOFCAUFOIMA 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 O 3 RENEWAL PERMIT a 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:Sa�-wApr> -I-eiwi3A1 141 I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: 'ry-TAt_ Co✓�"'fkAIA+M�,1.�'r C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: lo'coo / ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A -gpty MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR 3 DIESEL E:] 6 AVMTKONGAS UNLEADE❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ E]1EPREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 40 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNW40WN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 4 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 E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR(_) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IFAPPLIOABLE A. SYSTEM TYPE A U 1 SUCTION A# 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 4f 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 STEEL A U 3 POLYVINYL CHLORIDE(PVC)A4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CAT HOD ROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E:] 1 AUTOMATIC LINE LEAK DETECTOR 2 LINETIGHTNESSTESTING MONRORNG ❑ W OTHER V.TAN AK DETECTION VISUAL CHECKINVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING fi TANK TESTING � [—]INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT pPRPLICANTS N�AAME �I� - 6F6O- DATE 419-17 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO LAMB RS BELOW COUNTY 9 JURISDICTION 8 �-�--FA--�TIY 6 � TANK 8 pl] STATE I.D.# ( � 'it fj 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. FORMS (1291) FILE THIS FORM WITH THF"1CAL AGENCY IMPLEMENTING THE UNDERGROUND STOF -TANK REGULATIONS d.�j ` !P' � I F CIn , FORom1646