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STATEOFCAUFORMA ,,.��,o �. STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "�`� ' e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °•�,.o. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F;Z-ll 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZQ _ L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.6 S. MANUFACTURED BY: AJ KA C. DATE INSTALLED(MO/DAYA'EAR) UO' K" D. TANK CAPACITY IN GALLONS: a 000 ILTANKCONTENTS IFA-11S MARKEO.COMPLETE ITEM C. REGULAR A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ 1iUN EAD D 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM E::] 60 EMPTY ❑ 1 PRODUCT fC71 1D PREMIUM 4 �•ASAHOL ❑ 7 METHANOL 4AL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.6: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) Y❑w 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE F—] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (PnmAryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 7] 5 GLASS LINING ❑ 6 UNLINED �96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINIC YL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E::] 91 91 NONE 11-14 95 UNKNOWN 99 OTHER I,' �,"., � E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)L1IJ q.Y11Uy-v OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) N-K&Ayu IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(U) PRESSURE A U 3 GRAVITY A U W OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AQY 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 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AQRA UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 WERTITIAMONORING EK90 OTHER Uu.1 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 90 OTHER VI.TANK CLOSURE INFORMATION 1. TIMATEO DATE LAST USED(MOIDAY R 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME n /) ]� 1 GATE/T��' LOCAL A"G�+ENN'CY—USE OOONL[Y/Y THE{STATE I.ID..NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 9 FAULTY# TANK 9 STATE I.D.# m = I I I I I I I / L7 D ro 0 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. FORM B (12.91) � FILE THIS FORM W;6E LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDRAGE TANK REGULATIONS F0110m199f