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STATEOFCAUPORMA s` • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENT' -CLOSED ON ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED l DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V `..n (IT p I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNEWS TANK I.D.i j B. MANUFACTURED BY: Ali J,�. ��„� � •It•. C. DATE INSTALLED(MQ'DAVIVEAR) •ff.�"', D. TANK CAPACITY IN GALLONS: ^`^G?�[' G7 II.TANKCONTENTS IFA-11S MARKED,COMPLETE ITEMC. LIF(A.1) OTOR VEHICLE FUEL ❑ 4 OIL B. D. ® 1�UNLEADEULAND 3 DIESEL ❑ e AVIATION GAS 4 GASAHOL ❑ 7 METHANOL ETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1pUNLEAD DPREMIUM 5 JET FUEL HEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ;7 9B OTHER (DESCRIBE IN ITEM D. BELOW) OTMARKED. ENTER NAME OF SUBSTANCE STORED C.A. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ® 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F-12 SINGLE WALL ❑ 99 OTHER 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 '. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL FX 3 FIBERGLASS Q 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC B. TANKO 6 POLYVINYL CHLORIDE ❑ P MATERIAL ❑ 5 CONCRETE ❑7 ALUMINUM 6 100% METHANOL COMPATIBLE WIFR (PrimaryTAAk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOP ❑ 5 GLASS LINING y 6 UNLINED ❑ 95 UNKNOWN O W OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES F)J/ . NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3'VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:1 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) I`Tq OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 0 2 PRESSURE A U 3 GRAVITY A U M OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)ACID.4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 96 UNKNOWN A U w OTHER 0. LEAK DETECTION [g 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ S GROUND WATER MONITORING ❑.6 TANK TESTING ® 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED DUANTITV 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 DATE I'RINTEO{3I. ATURE) �� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION FACT TANK 9 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. FILE THIS FORM WITH THS'OCAL AGENCY IMPLEMENTING THE UNDERGROUND STOP".E TANK REGULATIONS FORM 3 (12-91) FOR00NB.Rf