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STATE WATER RESOURCES CONTRpL BOARD • UNDERGROUND STORAGE TANK PER •^`'�°'�' MARK ONLY ❑ COMPLETEITAPPLICATION. FORM B Ww � ONE ITEM A SEPARATE FOR ❑ 1 NEW IM PER M FOR EACH TANK SYSTEM, 2 INTERIM P ^ ERMIi ❑ 3 RENEWAL PERMIT DBA OR FACILITY ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF I NAME WHERE TANK IS NFOR I loij L TAN INSTALLED: ❑ 6 TEMPORARY TANK CLOSURE K DESCRIPTION ❑ 7 PERMANENTLY CLO A. OWNER'S TANK 1.D.x COMPLETE ALL ITEMS- SPECIE / • 8 TANK REMOVED C DAT YIF UNKNOWN r E INS7ALLE0(MO/DAYryEgq) II.TANK6. MANUFACTURED BY: CONTENTS IFA-1 IS MAR A' ❑ i MOTOR VEHICLE FUEL GALLONS: KED,CCyOMPLETEITEM C. O. TANK CgpAC17y IN ><2 PETROLEUM 4 OIL ❑ 3 CHEMICALPRODUCT ❑ 90 EMPTY B C. ❑ fa REGULgq IS NOTMARKED, ED 95 UNKNOWN 1 PRODUCT UNLEADED 3 DIESEL ENTER NAME OF SUBSTANCE S70gEp ❑ 2 WASTE ED lb PREMIUM UNLEADED 4 GASH AVIATION GAS ❑ 6 III, TANK CONSTRUCTION ❑ 2 LEADED ❑ 5 JET FUEL ❑ Z METHANOL MARKONE ITEM ONLY IN BOXES q,R, ❑ 99 OTHER (DESCRIBE IN ITEM A. TYPE OF ❑ 1 DOUBLE WALL D. BELOW) SYSTEM �j( AND C,q- AlLURTI AT SINBOXD INDE C�A'S.x: AJ 2 SINGLE WgLL ❑ 3 SINGLE WALL WITM EXTERIOR LINER 4 SECONDARY CONTAINMENT B• TANK 1 BARES TEEL 85 UNKNOWN MATERIAL ❑ 5 CONCRETE ❑ 2 STAINLESS STEEL FIBERVAULTEGTA LASS 9B OTHER (Primary'll 9 BRONZE ❑ 6 POLYVINYL CHLORIDE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W, C. REINFORCED PLASTIC ❑ 10 GALVANIZED ❑ Z ALUMINUM ❑ 1 RUBBER LINED STEEL ❑ 95 UNKNOWN ❑ B 100% METHANOL C.INTERIOR ❑ 2 ALKYD LINING COMPATIBLE W/FRP LINING ❑ 5 GLASS LNNG (((��, ❑ 99 OTHER LZ{I 6 UNLINED ❑ 3 EPDXY LINING IS LNNG MATERIAL CpMPATAAE ` ❑ 4 PHENOLIC LINING WITH 100 q M ❑ 85 UNKNOWN ❑ D.CORROSION ❑ 1 POLYETHYLENE WRAP ETfLWOL? YES 99 OTHER NO PROTECTION ❑ 2 cogTwp ❑ 5 CATHODIC PROTECTION ❑ 3 VINYL WRAP 91 NOW 4 FIBERGLAS E.SPILL AND OVERFILL SPILL CONTAWMEM ❑95 UNKNOWN S REINFORCED PLASTIC �i6RLLED(YEAR) A 1 a ❑ 99 OTHER IV.PIPING INFORMATION OVERFILL P CWG_ A IFABDIEGROUII OR U REVEN7'ON EDUIPM INSTALLED A. SYSTEM TYPE A�jfJ 1 SUC71pY A U 2--- RE NDERGROUND,BOTH IFAPPLICASLE EN7INST (YEAR) S. CONSTRUCTION A u 1 SINGLE WALL U 2 A U 3 GRAN 17Y DOUBLE W OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED A U 99 ER CORROSION A U S ALUMINUM U 2 STAINLESS STEEL A U TRENCH I Ili 95 UNKNOWN PROTECTION A U 9 GALVAI STEEL 6 CONCRETE A U POLYVINYL CHLOI I (pyp)A U 4 FIBERGLASS U 99 OTHER 10 CATHOOCP STEEL W'COATING LASS PIPE D. LEAK DETECTION ❑i AUTOMATCLNE LEAK OR ❑ ROTECTION A U 95 UNKNOWN A U 8 100% METHANOL CO 2 LWE TIGHTNESS TESTING A U 99 MPATIBLE W/Fqp V.TANK LEAK DETECTION � s OTHER ❑ RECON ❑gg OTHER- 1 VISUAL CHECK � 2 INVENTORY CIL ❑ MONITORING 3 VADpZEMON1Ton"G ❑ ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORill 91 NONE ❑ 4 AUTOMATIC iANKGAUGING I� 5 VI.TANK CLOSURE INFORMATION 95 UNKNOWN GROUND WATER I.ESTIMATED ILASiU 9(!MO/ppV/V� 2, V 99 OTHER -nnrr LLrr�(� II// INC.TED6 REMAIN NGUANTITY F THIS FORM HAS BEEN COMPLETED UNDER PEN, - GALLDNs 3'WAS TANK FlIIED APPLICANTS NAME ER✓UR) OF MATERIALWITH FP AND INERT ? VES ❑ (PRINTED 6 SIGNATUREI TO THE BEST Nolci/' MY KNOWLEDGE, lS TRUE AND CORRECT � LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER DATE 'POSED OF THE FOUR ERS BELOW STATE LD.# cTI COUNTY# NUMB ON# PERMIT NUMBER EXPIRATION IT AP I Y/GATE FACILITY THIS FORM MUST BE ACCOMPANIED BY A P PERMIT EXPIRATION DATE FILE THIS FORM WITH THE LOCAL Al PLICATION•FORM A,UNLESS A CURRENT FORMA HAS FORM B (12-91) EMENTING THE UNDERGROUND STORAGE TANK REGULATIONS . BEEN FILED. 0 FORIII