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SOJR STATEOFCAUPOFNA � E c'; STATE WATER RESOURCES CONTROL BOARD i '� UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM B w�`� "° . 04- COMPLETE A SEPARATE FORM FOR Eq TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ` 3 O /v . 1w I. TANK DESCRIPTION COMPETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: u �` C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK ENTS IFA-11SMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OILB. / C. -UNLEADED REGULAR 3 DIESEL O 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 00 EMPTY IL—JA/1 PRODUCT 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE 8J ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [Y2,SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Evrl BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 0 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER F7 �q� 1 RUBBER LINED ❑ 2 D LINING O 3 EPDXY LINING O 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING E4-fUUNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP [:] 2 ATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 98 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTI A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 ARE S EEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 AL UM 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 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMAj!glINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 WERTITIAMON ❑ 99 OTHER V.TANK LEAK DETECTION F-11 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ { AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 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 INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY x TANK# SRAJJ U j3 PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRAI=ATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE !//7Z F:91)/