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STATEOFCAUFDRNIA STATE WATER RESOURCES CONTROL BOARD ' •c ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B •m ^, n1 °3 COMPLETE A SEPARATE FORM FOR E�CH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑� � gMANENTLY CLOSED CNST ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE Val V 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Vd 7 W, O S 2 m'--�WLo ,C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.A O 8. MANUFACTURED BY: LIK C. DATE INSTALLED(MC(OAY/YEAR) l� 0. TANK CAPACITY IN GALLONS: U ' ILTANKCO EMS FA-I ISMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ laR REGULAR 3 DIESEL ❑ ;rMM ON GAS PREMIUM a GASAHOL ❑ 2 PETROLEUM ❑ BD EMPTY 1 'NASTECT ❑ IEUNLEADED 5 JETFUEL ❑ ANOL ❑ ] CHEMICAL PgOOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED � 99 OTHER (DESCRIBE IN . BELOW) 0. IF(A I)IS NOTMARKED. ENTER NAME OF SUBSTANCE STORED b C.A S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ OCUBUE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100. METHANOL COMPAT18LE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ tO GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INLININGR F-15 LINING LINING 8 UNLINED ❑ 95 UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING �VNYL WRAP F7 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ,u,/95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA80VEGROUNOOR U IFUNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTI A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AUN OW A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PM A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A V 8 CONCRETE A U 7 ST A U 3 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U TO CATHOOICPROTECTICN U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK OETECTOR ❑ 2 UNETIGHTNESSTESTING ❑ 31 [:] 99 OTHEq MONITORING V.TANK LEAK DETECTION ❑ I VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTTTNLMONITORNG ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED PATE LAST USED(MOOAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME DATE (PRWEU a bIGNANPET LOCAL AGENCY USE ONLY THE STATE L0.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW n,^ COUNTY a JURISDICTION x FACILITY x TANK s STATE I.D.n F3 Fl� S o C I � 'I PERMIT NUMG01 PERMITAPPROVEO BYNATE I PERMIT EXPIRATION DATE FORMS (9-901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM&PA l` 0