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STATE OFCAUFORMA y a <br /> �� STATE WATER RESOURCES CONTROL BOARD <br /> (2---UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EA NK SYSTEM <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 9 <br /> DBA OR FACE"NAME WHERE TANK IS INSTALLED: 1,7615— /jiv olw <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNERS TANK 1.0.0 © 8. MANUFACTURED BY: u� <br /> C. DATE INSTALLED(MO'DAYNEAR) 0. TANK CAPACITY IN GALLONS: <br /> 11.TANK COWENTS IFA-11SMARKED,COMPLETEREMC. <br /> REGULAR A, 1 MOTOR VEHICLE FUEL 4 OIL S. C. ❑ UNLEADED 3 DIESEL ❑ 8 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ IO PREMIUM 4 GASALWL ❑ T METHANOL <br /> UNLEADED 5 JETHER <br /> ❑ 7 CHEMICAL PgOOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 0. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.s; <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB.AND C.AND ALL THATAPPLIES IN BOX <br /> I BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 05 UNKNOWN <br /> A. TYPE OF Lll <br /> SYSTEM 2 3WISLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIq ❑ 90 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PNmuyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> ❑ I RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.ININ GR ❑ 5 GLASS LINING Cal UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER - <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION E2`591 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,80TH IF APPLICABLE <br /> SUCT A U 2PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> A. SYSTEM TYPE A U F <br /> B. CONSTRUCTION A U E W A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A UST A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 AEUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPAT18LE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99OTHER <br /> D. LEAK DETECTION C:] i AUTOMATIC LINE LEAK DETECTOR 2 LINE TDHTNESSTESTING ❑ 3 �ITER AL <br /> MONRORINO LSd� <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 8 TANK TESTING ❑ 7 INTERSTRIALMONRORING ❑ 91 NONE Q 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MOrDAVlY 2.ESTIMATED QUANTITY OF 3.WAS TANK F0LEO WITH <br /> 0 SUBSTANCE REMAINING _GALLONS INERT MATERIAL? VES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> IPPoME9 f SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY 8 JURISDICTION• FACILITY 8 TANK 9 <br /> STATE I.D.# 3 Y <br /> I/ a II I- I <br /> I II✓(�'� <br /> PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM 8 (S" THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FORMI-Pa <br />