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STATEOFCAUFORMA y) STATE WATER RESOURCES CONTROL BOARD s '� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 2 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT Q A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �/ p`z- GV . `�- /cw—, '� i�/_�, L G✓J I. TANK DESCRIPTION COMPLETE ALL ITEMS–SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.9 /c. , a. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) ✓-`G 1 D. TANK CAPACITY IN GALLONS: C, SD ILTANKCONTENTS IFA-I IS MARKED.COMPLETE ITEM C. A. [�&t MOTOR VEHICLE FUEL ❑ s OILB. C. ❑ 1. AUNLEADEO REGULAR 8 0 DIESEL ❑ g AVIATION GAS Q 2 PETROLEUM Q w EMPTY �1 PRODUCT Q lb PREMIUM 6 GASAHOL '❑ ]METHANOL UNLEADED 5 JET FUEL Q S CHEMICAL PRODUCT Q % UNKNOWN Q 2 WASTE �2 LEADED El 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A-I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX O AND A. TYPE OF ❑ I DOUBLE WALL Q 0 SINGLE WALL WITH EXTERIOR UNER UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) �%99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ s STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC S. TANK METHANOL COMPATIBLE WIF 6 POLYVINYL CHLORIDE T ALUMINUM B 100X. RP MATERIAL ❑ s CONCRETE ❑ ❑ ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL % UNKNOWN ❑ % OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING Q 0 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING Q 6 UNLINED �% UNKNOWN ❑' 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING F7 7 VINYL WRAP ❑ A FIBERGLASS REINFCRCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAWMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNOERGROUNO.BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U S GRAVITY A U W OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A(3�715 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIOE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STpihEE-L-�W�ICOATING A U 6 100% METHANOL COMPATIBLE WIFRP KNI PROTECTION A U 9 GALVANIZED STEEL U 10 CATHOOICPPOTECTA 4L UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ T MONRORIIA 99 OTHER L a� V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VADOZF MONITORING ❑ A AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING 6 TANK TESTING Q 7 INTERSTMALMONITORING ❑ 91 NONE % UNKNOWN Q % OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATED OATSq U 0 T 17AYIYR) 2 ESTIMATED OUANTRY OF 1 WAS TANK FILLED WITH YES ❑ NO❑ �4 SUBSTANCE PENIAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE PRINTE0651GNATJRCI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY�9 JURISDICTION 9 FACILITY 9 TANK 9 r.� STATE I.D. W II =1 I I I� PERMIT NUMBER PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0mA6diS