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�o STATE OF CAUFORNA STATE WATER RESOURCES CONTROL BOARD Wyo� .aA UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B , o m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF WFORMATION ❑ 7 PERMANENTLY CLOSED TAN MARK ONLY ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT' = 8 TEMPORARY TANK CLOSURE= 8 TANK REMOVED ONE REM FACILITY I SITE NAME WHERE TANK IS INSTALLED:.-�ir- f � I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.i� B. MANUFACTURED BY: ��-�p4 C. YEAH INSTALLED C(/J D. TANK CAPACITY IN GALLONS:�Vt/O ILTANKCONTENTS IFA-11SMARKED,COMPLETE REMC. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GA,SAHOL ❑ 5 JETFUEL ❑ 8 AVIATION GAS ❑ ❑ -per❑ 7�M�EfNANOL,/ ❑ 99 OTHER (DESCRIBE IN REM D. BELOW 80 EMPTY 95 UNKNOWN 2 WASTE D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.A: III. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXES A B,ANOC.ANDALLTHATAPPLIESINBOXD A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER [7T-95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 5 CONCRETE (Pnmwy Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑195 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LW WG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED D 9 UNKNOWN ❑ 99 OTHER LINING L9 LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7_ YE$__ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE(MARK ALL THAT APPLY) 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 WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U KNOW 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 A U 8 100% METHANOL COMPATIBLE FRP PROTECTION A U 2 GALVANIZED STEEL A U 10 CATWMIC PROTECTION A U OWN A U 99 OTHER D. LEAK DETECTION A U 1 AUTOMATIC LINE LEAK DETECTOR A U 2 LINE TIGHTNESS TESTING A U W OTHER V.TANK LEAK DETECTION MARK ALLTHATAPPLY ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM� �o ST USED(Mo/YRI 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH l SUBSTANCE REMAINING GALLONS INERT MATERIAL7 YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERDU ,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DAT APPUCANTSNAME IPwNreo 43icKATunA7 FRANK SMITH LOCAL AGENCY USE ONLY COUNTY s JURISDICTION s FACILITY IDs TANK ID# ® �s F . PERMIT NUMBER PERMITAPPROVAL DATE TION DATE STATE SURCHARGE AMOUNT THIS FORM MUST BE ACCOMPANIED BY APERMIT APPLICATION•FORM A,UNLESS A CUNT FORM A HAS BEEN FILED. FORM B (1.90)