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STATEOFCAUFORMA e ` <br /> STATE WATER RESOURCES CONTROL BOARD s` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E::] 8 TANK REMOVED (0011 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z6/Lf'�'igL�'7O <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.0 a, K B. MANUFACTURED BY: v, <br /> C. DATE INSTALLED(MO'DAYWEAR) v, K D. TANK CAPACITY IN GALLONS: ZV D0 <br /> ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C. Q 1aUNLEADED e 3 DIESEL O 6 AVIATIONGAS <br /> 2 PETROLEUM a as EMPTY 1 PRODUCT 1b PREMIUM 5 JETFUEL J <br /> 4 ETFUEL <br /> L O 7 METHANOL <br /> UNLEADED Q <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL El 3 FIBERGLASS O 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> (PKm6ryTm91) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F-1 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— <br /> D.CORROSION F_� 1 POLYETHYLENE WRAP O 2 COATING F-1 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION Q 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A,�F UII��90 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AdP" UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A QD95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E] 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING ❑ MOKRORING <br /> MAL OTHER U. K. <br /> V.TANK LEAK DETECTION <br /> Ij 1 VISUAL CHECK F__] 2 INVENTORY RECONCILIATION F73 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGINGE::] 5 GROUNDWATER MONITORING <br /> F7 6 TANK TESTING Q 7 INTERSTITIAL MONITORING 0 91 NONE 95 UNKNOWN E] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRIMED A SIGNANREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> CO® JURISDICTION# FACILITY Tc T� <br /> STATE I.D.# 6 O U <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HASBEENFIfFn. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM (12-91) F011061/BR6 <br />