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• STATE OF CAU FORMA • 3 RENEWAL PERMIT ❑ STATE WATER RESOURCES CONTROL BOARDUNDERGROUND ❑ STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE a 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 (\ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC `❑ B. TANK MATERIAL ❑ 5 CONCRETE 1 Taw nFSCRIPTION CnMPI FTE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.% (.r /G`r B.��II B. MANUFACTURED BV: �d%rte �, C. DATE INSTALLED(MO/DAV/YEAR) / a/3 /-/--1D. TANK CAPACITY IN GALLONS: II TANIVrAKITCAITC -A.mu.o o�cTc rtruc [!114,MOTOR VEHICLE FUEL ❑ 4 OIL B.��II C. ❑ 1a PEGUL A DIESEL E]6 AVIATIONGAS A ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT 4 I ❑ Ib PRE IUM n`�T 5 JET FUEL 1:17 METHANOL UNL❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ WASTE ❑ 2 LEADED u 99 OTHER IDESCRIBE IN ITEM D. BELOW) 0. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: 111 TANIV rl1AIQTGIICTIAN UADVnMCIT UnNIVINROYP9A R ANnC ANOAII THATAPPIIFSINROXOANOE A. TYPE OF DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E::]3 FIBERGLASS (\ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC `❑ B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100X. METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1130% METHANOL? YES _ NO_ D. CORROSION F7,,,... 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ppp,,,...,,, ' !k- FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 999 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV_ PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A&)2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARESTEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL WI COATING A U p 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN 99 OTHERr"% D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑99OTHER V. TANK LEAK DETECTION / ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INF RMATION 1. ESTIMATED DATE LAST USED(MO/OAYA'R) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NOO SUBSTANCE REMAINING GALLONS INERTMATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION p STATE 04/o FACILITY S I TANK p^i i�6�8 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE -b q FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORMSM