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'1BOV f U STATE OFCAUFORMA `� c a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STO AGE TANK PERMIT APPLICATION• FORM B CO E A SEPARATE FORM FOR EACH TANK SYSTEM °.1,.°.w• MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT F-15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED OdNSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.0 03 B. MANUFACTURED BY: u� C. DATE INSTALLED(MOIDAY/YEAR) (��/ D. TANK CAPACITY IN GALLONS: ILTANKCO S IFA-11SMARKED.COMPLETE ITEM C. i MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEA ED DIESEL ❑ 8 AVIATION GAS A. PREMIUM n 4 GASAHOL ❑ 2 PETROLEUM ❑ e0 EMPTY 1 PRODUCT ❑ 1DUNLEAD D ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM O.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES INBOXD A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 RARE STEEL E] 2 STAINLESS STEEL F73 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (PfimiryTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% ME L9 YES_ NO_ D.CORROSION F71 POLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATIONFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCT A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A 1 SINGLE AL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ARE ST 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 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31jNTURITRAL ❑99 OTHER ORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 9 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LABT USED(MO/DAY R) 2.ESTIMATED OUANTITY OF // 3.WAS TANK FILLED W IYES NO SUB STANCEREMAINING `( GALLONS INERTMATERIAL7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRWED&SIGNATIIBE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 7oQ STATE I.D.# 3I I I / D PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT IRATION T FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. S // FOROro1B.R0