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STATEOFCAUFORMA `.W STATE WATER RESOURCES CONTROL BOARD ` UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ °..,. ONE REM ❑ 2 INTERIM PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLO SITE ❑ 4 AMENDED PERMIT 6 TEMPOfUgY TANK CLOSURE ❑ # TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ' A. OWNER'S TANK I.D.# 'Z B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAVHEAR) I� 1d D. TANK CAPACfTY W GALLONS: ILTANKCONTENTS IFA-I ISMARKED,OOMPLETE ITEM C. A JK 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1iREGULARUNLEADED 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY �'1 PRODUGT 10 PREMIUM 4 GASAHOL O UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT D5 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED e 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED V OL L. C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNIPIOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ® I BARESTEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 10D% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH FAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU2 PRESSURE A U 3 GRAVITY A U 99 OTHER B, CONSTRUCTION ACU`J/ SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 SAKE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 1W% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 00 OTHER D. LEAK DETECTION �1 AUTOMATIC LINE LEAK DETECTOR X2 LINE TIGHTNESS TESTING ❑ 3 90 MONRORING ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ni 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED ` R2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 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 APPLICANTS NAME (PNMCDa Sn TUM DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS kMPoSED OF THE FOIR NUM RS BELOW COUNTY# JURISDICTION# k FAQIIMY# - TANK# I STATE LDA �r�r /w PERMIT NUMBERPERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (tz,sl) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS �i ti01 FOR9m16.9