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• STATEOFCAUFOWA • -°`°� c STATE WATER RESOURCES CONTROL BOARD '� �+ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "� "° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM re MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE 8 TANK REMOVED CLOSED SITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 41, QD a I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# f� p. S. MANUFACTURED BY.- DATE Y: a iilw df C. DATE INSTALLED(MO(DAV/YEAR) I ••• O D. TANK CAPACITY IN GALLONS: `• -�'Ca IIL-- C ENTS IFA-11SMARKED,COMPLETE ITEM C. A. Ey 1 MOTOR VEHICLE FUEL ❑ 4 OIL g. a REGULAR 2 PETROLEUM C' UNLEADED 3 DIESEL ❑ S AVIATION GAS ❑ ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM 4 GASA40L ❑ 7 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN REM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER le 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ^❑'7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrlmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 1?*9 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERLINED 2 ALKVp LWING ❑ 3 FPDXV LINING ❑ 4 PHENOLIC LINING C.INTERIOR s cuss LINING ❑ LINING ❑ Q 9 UNLINED 5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ,r UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY U S9 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 PROTECTION A U 9 GALVANIZED STEEL A U B 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION U 5 UNKNOWN p U 99 OTH R D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR O2 LI NE TO TESTING31N SITIAL ❑ 9 OTHER „ V.TANK LEAK DETECTION MONRORING ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ S TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NO ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH GALLONS 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 A SIGNATURE) PATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW T 11i !f. STATE LDALDACOUNTY If JURISDICTION# F TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 7r/✓ 7� FOROM&M