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STATE OF CAUFOFNA G" P STATE WATER RESOURCES CONTROL BOARD w� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - DORM B o J COMPLETE A SEPARATE FORM FORE TANK SYSTEM. MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EVS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ' E DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY 1F UNKNO A. OWNER'S TANK I.D.s 'D& B. MANUFACTURED BY: tt/7 9- C. DATE INSTALLED(MOIDAYNEAR) 0. TANK CAPACITY IN GALLONS: C-) C , 11.TANK C NTENTS IFA-1 IS MARKED.COMPLETE ITEM C. to REGULAR ❑ 3 DIESEL 6 AVIATION GAS El 1 MOTOR VEHICLE FUEL 4 OIL S. C. UNLEADED ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1h PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF Q/DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F72 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 0 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED VALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 715 GLASS LINING NLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 1S LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION F7 1 POLYETHYLENE WRAP ❑ 2 COATING F 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F75 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GR UND IFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 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 95 UNKNOW A U 99 OTHER C. MATERIAL AND A U I 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 8 CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UJ 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IMONITORING ERSTiL 7] 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑yAUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE95 UNKNO ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 72- TIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO17:1UBSTANCE REMAINING GALLONS INERT MATERIAL T THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER.IURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED III SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION it FACILITY# TANK# STATE I.Q.# ❑ �❑ �� PERMIT NUMBER PERMIT APPROVED BYIDATE 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, FOROM48-PA