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�•ou, STATE OFCIWPoRlBA ^� 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 CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED /L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: h -r C'A' 5--3 -7, J I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a 9— B. MANUFACTURED BV: C. DATE INSTALLED(MOfDAYNEAR) _ D. TANK CAPACITY IN GALLONS: 0 0 ILTANKCONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B. D• IaUNLEA0AR E0 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY t PRODUCT ❑ 16PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN a 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)ISNOTMARKED. ENTER NAME OFSUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCT) N MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 UBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 MN INUM F-18 100% METHANOL COMPATIBLE W/FRP (Primary Tank) g BRONZE ❑ 10 GALVANIZED STEEL 95 UNIWOW98 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING C.I uN LI F-15 GLASS LINING ❑ 8 UNLINED UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 5 UNKNOWN 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 B CONCRETE A U 7 STF,F,L W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U)96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 RSNL MONITORING ❑ gg OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPORMONITORING❑ 4A MATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING �� ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE 1.0.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STT LD# � = O d000 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F090Q9439i