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STATE OF CAUWRNA � �^ STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATK N ❑ T PERMANENTLY=Sr SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE OBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 D d S T P-A,G-AW 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.0 1 1 B. MANUFACTURED BY: C. DATE INSTA EO(MCIOAY/YEAR) Cl D. TANK CAPACITY N GALLONS: II.TANK NTENTS IF 4115 MARKED.COMPLETE ITEM C. A. � I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1+U LEA EO 7 DIESEL ❑ a AVIATION GAS1-7 I GASAHOL 2 PETROLEUM ❑ SO EMPTY f PRODUCT ❑ IbUNLEADED 5 JETFUEL ❑ T METHANOL 7 CHEMIOALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 19 9y OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.&S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.ANOC.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 1 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 1 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REWFORCED PLASTIC MATERIAL ❑ 5 CONCRETE I❑ a POLYVINYL CHLORIDE (❑ T ALUMINUM ❑ 8 100% METHANOL COMPATISLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER '�`❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ S EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION u I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL MAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 9S UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U ° GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 7 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 2 POLYVINYL CHLORIDE(PVC)A U • P18ERGLASS PIPE lflflf CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U T STEELWCOATING A U 8 1W% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ I AUTOMATICINELEAKDETECTOR 2 LINE TIGHTNESS TESTING ❑ U MOKRORaKi I❑ 99 OTHER .TANK LEAK DETECTION (❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 0 VAPOR MONITORING❑ 6 AUTOMATIC TANK GAUGM ❑ 5 GROUND WATER MCNITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAYNR) I 2.ESTIMATED OUANTITY OF I 1 WAS TANK FILED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS NERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (MNTE9 A 916NATUPEf / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION I FACILITY I TMNK L—I---L--L--9--KJ STATE I.D.# PERMIT NUMBER /( / n I PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM/MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PGR MS-1N mow 1./