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STATEOFCAUPDRNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B � a COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ S RENEWAL PERMIT S CHANGE OF INFORMATION ❑ PERMANENTL SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMO D O DBAOR FACILITY NAME WHERE TANK IS INSTALLED: N S7 S 3 I. TANK DESCRIPTION COMPLETE ALL REINS— SPECIFY 6 UNKNOWN A. OWNER'S TANK LD.t B. MANUFACTURED BY: C. DATE WSTALLED(MO/OAY/(EAR) 0. TANK CAPACITY IN GALLONS: LED II.TANK CONTENTS FA-IISMARKED.co4PLElvrrEmc. A. ❑ I MOTOR VEHICLE FUEL a OIL B. C. ❑ REGULAR EA ED 8 S DIESEL ❑ 6 AVIATK)NGAS ❑ 2 PETROLEUM ❑ 60 EMPTY n 1 pOUCT ❑ f-PREMNM I—� A��'�L ❑ 7 METHANOL ❑ 7 CHEMICALPRODUCT ❑ 95 UNKNOWN „1��i/2 WASTE ❑ 2 LEADED D y.,,Jy"'FUEL �/ 90 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED D 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANOC.AND ALL THAT APPLIES INBOXD A. TYPE OF ❑ I,DOUBLE WALL ❑ S SINGLE WALL WITH EXTERIOR ERIOR LINER ❑ 95 UNKNOWN SYSTEM I� 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANIq ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ 0 EPDXY LINING ❑ A PHENOLIC LINING LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLIN06 UNKNOWN❑ ❑ 90 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ yEDATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [R'91 NONE ❑ 95 UNW40WN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNOERGROUND OTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE U GRAVITY A U W OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U O LINED TRENCH A UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 5 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM p CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL U 0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATICLINE LEAK OaTeCTOR ❑ 2 LINETIGHTNI 1 TESTING ❑ ML 99 OTHER LgNROgWO ❑ V.TANK LEAK DETECTION -1 ❑ 1/GISUAL CHECK ❑ 2 INVENTOgY RECONCILIATION ❑ 2 VAPOR MONITORING A AUTOMATIC TANK GAUGING❑ 5 GROUNOWATERMONITORING N LryC�/6 TANK TESTING ❑ 7 NTEq$TR AL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOrOAWYR) i ESTIMATED QUANTITY OF 7.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIALT YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME IPn D A 6 AMREI �D DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 6 FACILITY 6 TANK 6 STATELD.# = QOle ID O PERMIT NUMBER I PERMIT APPROVED BY/DATE PESMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIOO//N-FqRk A,UNLESS A CURRENT FORM A HAS BEEN FILED. I//,},G/n/l FORamaB-M