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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 'e 0 COMPLETE A SEPARATE FORM FOR EACH K SYSTEM MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 2r5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE, ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a B TANK REM DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY E UNKNOWN A. OWNERS TANK I.D.8 Z B. MM UFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) L, D. TANK CAPACITY IN GALLONS: 676) II.TANK CONTENTS IFA-1 IS MARKED.COMPLETEITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ Ia(RNEGEULARO 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY DUCT ❑ 1D PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 90 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM C2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL C:�.tl-YONKNDWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑�3 EPDXY LINING ❑ A PHENOLIC L941W 2T—w- - I V C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN O W OTHER LINING G LINING MATERIAL COMPATIBLE WITH 100Y. METHANOL] YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE FEr UNKNOWN n OTHER IV.PIPING INFORMATIO CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF _. "�E A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 SACOATING A U 8 IOD% METHANOL COMPATIBLE WIFRP PROTECTION U B GALVANIZED STEEL A U 10 CATHODIC PROTECTION p I UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING MCM00RNG ❑ W OTHER V.TANK LEAK DETECTION P�6 CKEfT�INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK TESTING ❑ 7 INTERSTITIALMONGORING ❑ 91 NONE ❑ 95 UNKNOWN ED M OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH SUB STANCE REMAINING GALLONS INERTMATERtAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (RPoRTE9 A&G MRO LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOrrW7 COUNTY 9 JURISDICTION x FACILITY# 'I JAI TAW 9 00? STATE I.D.# 00 y b L-5 o Z PERMIT NUMBER PERMIT APPROVED BWDATE PERMIT EXPIRATION DATE FORMS (9-9 ) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / F0119M1BAA