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'ii a t \� STATE OF CANFORNA �ww a STATE WATER RESOURCES CONTROL BOARD C UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B CO ETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT IK 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (pq,3 (f/ .p{-�✓ie L U S tp I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN & OWNERS TANK I.D.s Oo B. MANUFACTURED BY: Perk i n S C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS: D000 lo II.TANK ENTS IF A•1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. ❑ 1AlNEGLEA ARD3 DIESEL ❑ 5 AVIATIONGAS ❑ 2 PETROLEUM ED so EMPTY 1 PRODUCT O 10 PREMIUM 4 GASAHOL ❑ 7 METHANOL E:] ❑ ❑ ❑2 WASTE 2 LEADED UNLEADED 99 JOTHERETFUEL(DESCRIBE IN IRU D. BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 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.8,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTEDTANK) ❑ W THER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS a STEEL CLAD FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE W/FRP (PdawyTMdt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ t RUBBER LINED ❑ 2 ALKYD LINING XY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 9 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ ?3/41 YL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGRDUNDOR U IF UNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 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 UNKNO A U w OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)p U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELMI/CO A U S 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION p U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING�TOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDOUANTITYOF 3.WASFILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED BSN ATDRET LOCAL AGENCY USE ONLY 1 THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW G COUNTY# JURISDICTION* FACILITY# �TANK# STATE I.D, IIMC0(o�® = I I I _I _Ilou 10/111/i/ PERMIT NUMBER PERMIT APPROVED BY/DATE 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. FORODM&M