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�./ STATEOFCAUFORMA -�,a"••'�.. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B -m �, o COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM - �""°""�� MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM F-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE a 8 TANK REMOVED s, DBA OR FACILITY NAME WHERE TANK IS INSTALLED: qpt /siOw e(w 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.s B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANKC ENTS IFA-71S MARKED.COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4OIL B. C aWJ GLEADUE� 8 3 DIESEL ❑ e AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY �PROOUCT ❑ iD PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT � 95 UNKNOWN ❑ 2 WASTE 2 LEADED 9B OTHER (DESCRIBE IN ITEM D. BELOW) M IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED CAS#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 LE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IOD% METHANOL COMPATIBLE W/FRP (PrimaryTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS I NWG 1311's UNLINED 96 UNKNOWN 99 OTHER LINING ❑ ❑ ❑ IS LNING MATERIAL COMPATIBLE WITH 100% METHANOL] YES_ NO— D.CORROSION F-1I POLYETHYLENE WRAP ❑ /"""TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUNO.BOTHIFAPPLK:ABLE A. SYSTEM TYPE A U SUCTIO A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SI LE WAL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 7 RE ST A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTH D. LEAK DETECTION Q I AUTOMATIC LINE LEAK DETECTOR 2 LINE TGHTNESSTESTING ❑ 3 WTERSTITIAL 99 OTHER MONRORNO V.TANK LEAK DETECTION ❑ I VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST US (MOIDAYIYA) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �Q��q� SUBSTANCE REMAINING _GALLONS INERT MATERIAL) 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 jpmw Oa SIDNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 3 9 1 1115- a1 1 1 1 11 Dl:/ PERMIT NUMBEfl 7 PERMIT APPROVED SWOATE PERMIT EXPIRATION DATE FORM B (490/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORNIMB-R3 r ��