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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B " COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, ,,,\\\,,,��,,, `•' RK ONLY ❑ 1 NEW PERMIT ED 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO " ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AR1;,0 FiD�.C, I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.t \ B. MANUFACTURED BY: UA?�R.PBWN ---------------- C. DATE INSTALLED(MWDAYMEAR) �\1 D. TANK CAPACITY IN GALLONS: , II.TANK CONTENTS IFA-11SMARKED.CDMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. LSI Ia REGUL AR ED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ® 1 PRODUCT 1E PREMIUM A GASAHOL 6 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED g 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.B: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC,AND ALLTHAT APPLIES INBOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ A STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E::]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPM ENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFA9OVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A, SYSTEM TYPE A U 1 SUCTION AC9 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SNGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AUA FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATINO A U 8 IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZEDSTEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER A� D. LEAK DETECTION ® 1 AUTOMATIC LINE LEAK DETECTOR ® 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑W OTHER /a V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS ED( Y>nRI 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 'L\ SUBSTANCE REMAINING ^�' GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT IPRI APPNiELICANTSOa NAME 51GKATUPEI DATE \� Q A LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMP SED OF THE FOUR NUMB RS BEON COUNTY Al JURISDICTION 8 FACIL 8 TANK 8 STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM (1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS - \1 RXIOCOILM