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• A � STATE OFCAUPoRNA • �eeo STATE WATER RESOURCES CONTROL BOARD '� c UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ❑ B TEMPORARY TANK CLOSURE ❑ g TANK REMOVED / l DBA OR FACILITY NAME WHERE TANK IS INSTALLED: .415 (J 9D L%�I I. TANK DESCRIPTION COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN AM;;g;]u B. MANUFACTURED BY: CwV,00OKI D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. O1 MOTOR VEHICLE FUEL ® 4 OIL B. C. ❑ 1.REGULARNLEADED 3 DIESEL El g AVIATION GAS 2 PETROLEUM ❑ 60 EMPTY ❑ 1 PRODUCT 7b PREMIUM 4 GASAHOL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE ❑ UNLEADED 5 JET FUEL 7 METHANOL ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED -ft z; ^_ LAL— C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 85 UNKNOWN ❑ 89 OTHER C.INTERIOR F--11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:] 97 NONE ®g5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA80VEGROUNDOR 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 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AQ BS UNKNOWN p U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 4 FIBERGLASS PIPE A U 7 STEEL COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A&)95 UNKNOWN p U 89 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONROflINGL �99 OTHER U�C V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING "®,91 NONE ❑ 95 UNKNOWN ❑ gg OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAT D D TE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF JF' SUBSTANCE REMAINING 3-WAS TANK FILLED WITH LIuK GALLONS INERT MATERIAL? YES ❑ NOY < THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE IQ,# COUNTY# JURISDICTION# FACILITY# TANK# - �--,\® � � p � E;PERMITNUMBER O O O PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE FORM B (480) T ST BE ACCOMPANIED BY A PERMR APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROM&R4 —)