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• • �sow+ + STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD s4' t, UNDERGROUND STORAGE TANK PERMIT APPLICATION+ FORM B "Wim, �: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM `"�^�+^'' MARK ONLY ® 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE ❑ g TANK REMOVED Iq DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a Z B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAVA'EAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A. E;?'IMOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ 1a RE GULAR EUL A ED B 3 DIESEL ❑ g AVIATpN GAS 2 PETROLEUM BO EMPTY 1 PRODUCT DPREMIUM A GASAHOL UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL Q 3 CHEMICAL PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX O AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 19D% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UN104OWN ww❑vv 99 OTHER ❑ 1 RUBBER ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING ER LINED ❑ C.INTERIOR 5 GLASS LINING ❑ 8 UNLINED ❑ ❑ ❑ B5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH IOD% METHANOL? YES NO— D.CORROSION ❑ 1 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 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A100% METHANOL COMPATIBLE W/FAP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN AU9 OTHER D. LEAK DETECTION x1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONRORING ❑W OTHER V.TANK LEAK DETECTION _I 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN 1❑L ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH lu SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO L] THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME / (PRI +NTED!SnIG ;UR6r� _ i) •, / L�Y�A YFciCIA � D LOCAL AGENCY USE ONLY THE STATE I.DD..NUMBER IS11COMPOSED OFTHE FOUR NUMBERS BELOW STATE I.D.# a 3 I S COUNTY# JURISDICTION# FACILITY#M3J76 TANK# PERMITNUMBER PERMIT E%PIRATION DATE R PERMIT APPROV�TE O (5, S B 1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORME (1291) FILE THIS FORM WITH jrAL AGENCY IMPLEMENTING THE UNDERGROUND SIGE TANK REGULATIONS FORONI&R{