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STATE OFCAl1FaNA STATE WATER RESOURCES CONTROL BOARD ,y•'.o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B '"� :s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `��,.o- ARK ONLY �E] 2 W PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 ORANGE OF INFORMATX7N ��yy55 ONE REM ERIM PERMIT 4 AMENDED PERMIT �yJ 7 PERMANENTLY CLO SITE ❑ ❑ B TEMPORARY TANK CLOSURE 11� x TANK REMOVED DBA OR FACILITY NAME WHERE TANK ISMS 1,1 1 :1 alj Z`1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN O A. OWNERS TANK I.D.t S. MANUFACTURED BV: NNImuUN C. DATE INSTALLED(MQDAY/VEAR) 10 D. TANK CAPACITY IN GALLONS: G II.TANKCONTENTS FA113MAR�D.COMPLETEEEEITEM C. A. ® 1 MOTOR VEHICLE FUEL ❑ { OIL B. C. ❑ 1iREGULAR UNLEADED 3 DIESEL ❑ S AVIATON GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT fG 1b PREMIUM 4 GASAHOL ❑ 7 METHM1pL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑51 2UN ADD 5 JET FUEL g 99 OTHER (DESCRIBE IN ITEM D. BELOW) D IF(A.1)IS NOTMARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARKONE ITEMONLYINSOXESA,BAND C,AND ALL THAT APPLIES IN BOXD ANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ycl 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 00 OTHER B. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary TNM) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ ®5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ oo 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 ❑ 91 NONE W 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILLCONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLK.ASLE A. SYSTEM TYPE A U 1 SUCTION A&2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTK)N AU1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LNED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AUG4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 W 1 AUTOMATIC LINE LEAK DETECTOR 2Er 2 LINE TIGHTNESS TESTING ❑ MDNRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION [D3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I� 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST US O/D V R) 2,ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO Z� 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 APPLICANTSNAME BL\\ DATE r� (PNN1E9 a 9gKATUREI ��V\ �{1 9r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER ISOMPOSED OF THE FOU(NUMBWS BELOW STATE I.D.# COUNTY x JURISDICTION x ITY x TANK x t O PERMIT NUMBERPERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA NAS BEEN FILED. G FORMS (1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORpIDrBN6