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STATE OF CAU FORMA STATE WATER RESOURCES CONTROL BOARD z'y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B / COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION E:] 7 PERMANEN Y TE ONE ITEM ❑ 2 INTERIM PERMIT F--] C AMENDED PERMIT 6 TEMPORARY TANK CLOSURE [:] 8 TANK RE OVEDI 017 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ) ] ;'p /)e-f 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.# S. MANUFACTURED BY: C. DATE INSTALLED(MONAY/YEAR) U `. D. TANK CAPACITY IN GALLONS: It.TANK C ENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ t OIL 8. C. ❑ 1#REGULAR 3 DIESEL D ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib BIM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 L LADEDD 8 99 JOTHER ET L(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ M SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I HARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimuyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ t PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING F-16 UNLINED F-195 UNKNOWN E] N OTHER LS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I 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 A U 96 UNKNOWN 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 6 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UN104OWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINELEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING INTERSTITIAL ❑ 09 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ t AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMOMTORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDWANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE 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 IPRIRtE0ASIGNAT11RE1 LOCAL AGENCY USE qNLY- THESTATf I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW J /� LNTY# JURISDICTION 9 FACILITY# TANK# STATEe 3 d a PERMIT NUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE FORM a(9.90) tM FaRBE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.