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STATEOFCAUFORNA • 'ew",•�.,co STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM `"'•�^"'� MARK ONLY ❑ 1 NEW PERMIT ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATICN ❑ PERMANENTLY SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT In 8 TEMPORARY TANK CLOSURE 8 TANK REMO DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6Cjsi �li✓d Lit I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: L C. OATS INSTALLED(MO/DAVA'EAR) / D. TANK CAPACITY IN GALLONS: ILTANK NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. Fr 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IaREGULAFI 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT IDPREMIUM 4 GASAHOL ❑ 7 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 9B OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 8,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO UNING ❑ S EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 C"SS LINING5 UNLINED LINING ❑ ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NCNE ❑ 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 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 a CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING J STI ML ❑ MONITORING gg OTHER V.TANK LEAK DETECTION I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATUREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDA COUNTY# JURISD�—iJ TION# FACILITY# TANK 13� V PEflMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DAT FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR02143Rt