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STATE OF'AUFO STATE WATER RESOURCES CONTROL BOARD g50Y' f LfMARKONLY UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.❑ 1 NEW PERMIT❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION2 INTERIM PERMIT O 4 AMENDED PERMITITY NAME WHERE TgNK IS INSTALLED: ❑ 6 TEMPORARY TANK CLOSURE ❑ ' PERMANENTLY CLOSED O B TANK REMOVE I. TANK DESCRIPTION COMPIETEALL IT1 11EMS-- • , s O A. WWNE.,'S TANK I.D.a SPECIFY IF UNKNOWN C. DATE INSTALLED(M—TlyEAR) B. MANUFACTURED By: II. IFA -1 D. TANK CAPACITY IN GALLONS: G' -1 IS MARKED.COMPLETE ITEM C. J A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. PETROLEUMEl ❑ 1a REGULAR 80 EMPTY ❑ 1 gOC UNLEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT PDUCT ❑ ID PREMIUM 4 GASAHOL ❑ 6 AVIATION GAS ❑ 95 UNKNOWN UNLEADED ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 S WATE ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES BOX D AND C.a.s.e: A. TYPE OF ❑ 1 DOUBLE WALL ED SYSTEM SINGLE WALL WITH EXTERIOR LINER 95 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑❑ 99 OTHER UNKNOWN B. TANK ;W� I BARESTEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (Prima Tank) ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ry ❑ 9 BRONZE ❑ 10 GALVANIZED❑ STEEL ElNKNOWN 6 1�O METHANOL COMPATIBLE W/FRP❑ 95 U C.INTERIOR - 1 RUBBER LINED ❑ 2 ALKYD LINING - ❑ 99 OTHER LINING ❑ 5 GLASS LINING ❑6 UNLINED 3 EPDXY LINING E] 4 PHENOLIC LINING MI ❑ IS LINING MATERIAL COMPATISLE WITH 100% METHANOL? 95 UNKNOWN ❑ 69 OTHER YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING d PROTECTION ❑ 5 CATHODPROTECTiONX 91 NONE ❑ 3 VINYL Wqpp IC ❑ 4 FIBERGLASS REINFORCED PLASTIC;l, E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(VEAq) ❑95 UNKNOWN ❑ 99 OTHER OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) o IV.PIPING IN CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAppLICABLE A. SYSTEM TYPE A 1 sucTloN 1 SINGLE WgLA U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U L A U 2 DOUBLE WALL A U 99 OTHER A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTW A U 2 STAINLESS STEEL A U 3 POLN--L CHLORIDE(PVO)p U 4 FIBERGLASS PIPE CORROSION A U s AUA4YAAd A U 6 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 7 SiEEI5 UNKNOWWIrOATING A U 8 tab% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAKDETECTOq A U 95 UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING � 3 V.TANK LEAK DETECTION MONITORING 99 OTHER ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING g1 NONE ❑ 5 GROUND WATER MONITORING ❑ 95 UNKNOWN 99 OTHER VL TANK Cl OSUAIF/NFORMA77ON ' 1.ESTIMATED DATE LA US (MO/DAY/Vq) 2.ESTIMATED QUANTITY OF tO SUBSTANCE REMAINING J D GALLONS 3 WAS INTANK ERTMATERIpLITH T /S FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,A APPLICANTND TO THESES, OF MY KNOWLEDGE, IS TRUE AN CORRECT S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# °O,"-NrY," JURISDICTION "I fxS ILIyJI FACI� TANK PERMIT NUMBER PERMIT APpgOVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS (12.91) FILE THIS FORM WITH)LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST AGE TANK REGULATIONS a - q� FOR0991SR6