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STATEOFCAUFORMA :• <o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B , o p S4sowN� TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I D 8 Z B. MANUFACTURED BY: Qi/I' C DATE INSTALLED(MO/DAY/YEAR) C� 8"' D. TANK CAPACITY IN GALLONS. TE ITEM C ILTANKCONTENTS IFA -11S MARKED, COMPILE COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM A MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ 3 RENEWAL PERMIT 4 AMENDED PERMIT ❑ S CHANGE OF INFORMATION 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 8 TANK REMOVED / DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 737- i! O ❑ 2 LEADED 98 OTHER (DESCRIBE IN REM D. BELOW) TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I D 8 Z B. MANUFACTURED BY: Qi/I' C DATE INSTALLED(MO/DAY/YEAR) C� 8"' D. TANK CAPACITY IN GALLONS. TE ITEM C ILTANKCONTENTS IFA -11S MARKED, COMPILE _.._. ... __-. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. ❑ DIESELOA,SAHOL ❑ 6 AVIATION GAS C. 1aREGULARUNLEADED A ❑ 2 PETROLEUM ❑ BO EMPTY ��RODUCT ❑ 4 ❑ 1bUR UNLEADED 5 JET FUEL ❑ ]METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 98 OTHER (DESCRIBE IN REM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. x v nnuntorlPTl/1A1 A 0 AMnn AMn All TWAT APPI IFS IN RDX0 111. Im.•n vvnv,uvv• .. ....�.... �.._.. _... _.._. ... __-. A 1 SIcTION A U 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 2 DOUBLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL (Primuy Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �NKNOWN ❑ 99 OTHER LINING PROTECTION A U 9 GALVANIZED STEEL A U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO— D. LEAK DETECTION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINY WRAP 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE —u 6/UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SIcTION 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 A U 1 RARE STEEL A U 2 STAINLESS STEEL A POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND ///U��TTT3 CORROSION A U 5 ALUMINUM A U 6 CONCRETE STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CAT140 I ROTECT A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESSTESTING ❑ ] MONRORINGL ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF - I 3. WAS TANK FILLED WITH SUB STA NCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPNNTEO851GNANREI LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ` COUNTY # JURISDICTION # FACILITY x # STATE I.D.# 5111 ® g 3 p a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE �7 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOROm49-114 �,�30