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STATEOFCAUFORMA • a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B COMPLETE 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 ❑ 6 TANK REMOVED 17 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK LD.4 U I S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) v / D. TANK CAPACITY ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEMC. A, 1 MOTOR VEHICLE FUEL 4 OIL 9. C. tAUNLEA EZ"AD 3 DIESE ❑ 6 AVIATION GAS O 2 PETROLEUM ❑ BO EMPTY E!�ll PRODUCT 1b PREMIUM IIIIn��III1 4 GAS L ❑ 7 METHANOL UNLEADED u O 99 OTHER L(DESCRIBE IN ITEM D. BELOW)3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED u D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.v 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 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B IOD% METHANOL COMPATIBLE W/FRP (PrimaryTmk) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINE ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED95 UNKNOWN ❑ 99 OTHER LINING- IS LINING MATERIAL COMPATIBLE WITH 100'A METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ^ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [:D91 NONE 1 95 UNKNOWN ❑ 99 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 A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AjV SINGLE WALL A U 2 DOUBLE WALL A U 3 LINE TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B LOOK METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AT,)S UNKNOWN A U 99 OTHER 3 INTERSTITIAL D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR "2 UNETIGHTNESS TESTING ❑ MONITORNG ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ff7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USE(MO/DAY/YR) 12.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SK ATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY B JURISDICTION x FACILITY A TANK x STATE I.D# §TI / g y PERMITN'SER�, PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 14 y� FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 FOROOMB45