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51ATE OFCAUFOPMA ( STATE WATER RESOURCES CONTROL BOARD a fi UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORD FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGEOF INFORMATX3N ❑ 7 PERMANENTLY. CSED ON SITE ! ONE ITEM 2 INTERIM PERMIT ID 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE I TANK REMOVE7, } DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ! I. TANK DESCRIPTION COMPLETE ALL�+S- SPECIFY IF UNKNOWN jj � A. OWNER'S TANK L D.8 S. MANUFACTURED BY: i C. DATE INSTALLED;MOIDAY.YEAR) 0. TANK CAPACITYIN GALLONS: ` .11.TANK IFA•tISMARKc�.C^VP.ri�ITEMC. I a A. 1 MOTOR VEHICLE FUEL 4 OIL H. C ❑ ta'UNLEAd R 3 DIESEL ❑ E AVIATION GAS II 2 PETROLEUM 80 EMPTY 7 PRODUCT � 7bIU��D 5 E75FUELL C ue'I:/WOL r ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2�LFADEDI yy OTHER (DESCRIBE ri ,WM D. BELOW) HD. IF(A.1)15 NOT MARKED. ENTER NAME O=S_2S'ANCE STORED C.A.S.8: r III. TANK CO CONSTRUCTION UCTION MARK ONE-u ONLY IN BOXES A.B,ANDC.AND ALL THAT APPLES IN BOX O ANTE A TYPE OF 1 DOUBLE WALL I 3 SINGLE WALL WITH EXTERK]R LINER UNKNOWN _ ❑ SYSTEM 2 SINGLE WALL `I 4 SECONDARY CONTAINMENT I �99 OTHER ❑ VAULTED TANK) # UI BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS .I 4 STEEL CLAD W;FIBERGLASS GE:N=::CEO PLASTIC B. TANK — I ;` I MATERIAL ❑ 5 CONCRETE _ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM I 1DO% METHANOL COMPATIBLE i (PriMarrTank) ❑ 9 r,;o%. � 1D GALVAN�D STEEOTHERL ❑ 95 UNKNOWN L:p9 � _ 11�.i 1 Ai;EBER LINED I, 2 ALKYD LINING ❑ 3 EPDXY LINING' ❑ F4 PHENOLIC LINING C.INTERIOP 13 LINING ❑ 5 GLASS'LINING �Z,6 UNLINED El 25 UNKNOWN ❑ ;p9 OTHER fIS LINING MATER',AL COV-'A'c_c W;7k 100% METI�ANOL 7 YES— NO— D.CORROSION O_D.CORRDSION 1 1 POLYETHYLENE ti~;►v z COATING s VINYL w,A? !j I a FIBERGLASS REINFORCED P,;tS'4 PROTECTION 5 CATHODIC PRO?EC--CN �' $1 NONE ❑95 UNKNOWN ; ,1`92 01-HER f q i E.SPILL AND OVERFILL SPILL CONTAIN VEN'INS-ALLED(YEAR) OVERFILL PRE'VENTK)N EOUIPMENT INSTALLED(YEAC IV.PIPING INFORMATION CIRCLE A .=AFCVE G;D:IN70A U IF L'N7=_aGAOUN0,BOTH IF APPOCA LE p A. SYSTEM TYPE A 1 SjC710N A U 2 PRESSURE A U 3 GRAVITY j A)U 99 OTHER B. CONSTRUCTION A 'U 1 SINGLE wA_L A DOUBLE MALL A U 3 LINED TRENCjH A' U 95 UNKNOWN A U 96 C7-4E q f C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A V 3 POLYVINYL OHLOAIOE'(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W;COATING 0" A U 8 SOCK METHANOL COL=ATIBLE W/FflP PROTECTION A U 9 GALVAN:rD S EEL A U 10 CA7kODIC PROTECTION A U 95 UNKNOWN j A V"- OTHER E /teFt k D. LEAK DETECTION AUTOMATIC LIN_LEAK DETECTOR ❑ 2 LINE 7GN'7:FSS TESTINGF� �r]I+rt0R14G 99 OTHER��r V.TANK LEAK DETECTION if 1 VISUAL CHECK ❑ 2 INVENTORY R;CONCIL:ATIDN 3 VAOOZEMONITORING14 AUTOMATIC TANKGAUGING 5 GROUND ri'A:cflMONITORING ��t !j 'I 6 TANK TrS-IN.G 7 Inti-ERST17i4LL/CN;',^�a1VG � 91 NONE � 95 UN}NO1VN � Q 99 OTHEq I VI,TANK CLOSURE INFORMATION 1.ESTIMATED DA-E LAST USED;yOOAY.'YR) 1 I 2.ES'INATED O::Al;-,i?Y OF I 3.,WAS TANK FILLED w T� ) {] I S J STANCE tiEMt';;'�G GALLONS I INERT MATERIAL / S NO I THIS FORM NAS BEEN C0161PLETED UNDER PENALTY OF PERJURY,AND 7#fHE BEST F MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME ' , � � I! DATE , 1VAa s IA1U EI (J/_ ` `LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION N FACILITY 9,x TANK s STATE I.D.# PERMIT NUVBER PERMIT APPROVED BYrwATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS �DaM B (129+) I FOIRDCS16LQ6 �I