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ID'S UR � CC STATE OFCAUPORMA • A STATE WATER RESOURCES CONTROL BOARD 3 ° / UNDERGROUND STORAGE T PERMIT APPLICATION- FORM B COMPLETE A SEPARAT ORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERT 51 CHANGE OF INFORMATION 7 PER ANENTLY CLO E 1-131 ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PER IT ❑ TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c j SZ-U I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN P/d�✓ '' A. OWNER'S TANK I.D.* V rc B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY%EAR) Cill D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 ISMARKED,COMPUETV EMC. A. ❑ 1 MOTOR VEHICLE FUEL ❑ IL B. C. ❑ 1a REGULAR 3 DIESEL ❑ 6 AVIATIONGAS 4 GASAHOL ❑ 2 PETROLEUM 90 E ❑ 1bUIDEO ❑ 5 JETFUEL ❑ 7 METHANOL MPTY 1 PRODUCT NLEA ❑ 3 CHEMICAL PRODUCT ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL F72 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE [—] 6 POLYVINYL CHLORIDE F77 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP ❑ (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP [—] 2 COATING ❑ 3 WL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN E] 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 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 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 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING 3 INTERSTITIAL ❑ 99 OTHER V.TANK LEAK DETECTION (w�` ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING `�y�1 ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER \ VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WI SUBSTANCE REMAINING GALLONS INERT MATER 7 YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW DGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SIGNATURE) -/ I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTIO S�FA--CILI��TY#��--��,�--,� TANK# STATE I.D.# U LJ�_L�J LL_I PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIIIION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMAAS BEEN FILED. FORC0 B-N