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%4w STATE DFcwFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B =: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT D 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.S S. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) uQlAinuykl 1 D. TANK CAPACITY IN GALLONS: Q ILTANKCONTENTS IFA4 IS MARKED.COMPLETE ITEM C. A. U 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. iSUNLEADERD 3 DIESEL ❑ e AVIATIONGAS F-12 PETROLEUM ❑ SO EMPTY 1 PRODUCT 19PREMIUM 4 GASAHOL 7 METHANOL ❑ n`�-T ❑ ❑ 3 CHEMICAL PRODUCT E:] 95 5 JETFUEL 95 UNKNOWN ❑ 2 WASTE E::] 2 LEADED u 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER IX95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PdmwyTm*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)-ViN$FhAAI OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR)LAL ,K) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU02 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 95 UNKNOWN-AU 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 9 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WARP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Q`-Q'�95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONBORMO 99 OTHER 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 rV 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LA STUSED(MO/DAY/YR) QS_ 1 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ SUBSTANCE REMAINING ---e=LLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF AMY KNOWLEDGE, IS TRUE AND CORRECT APPL�IC�ANQ�T��SY+�NJ�A�ME �p /� DATE IPRn,tco s,— sEck TNS— l`� hk� R- )(� I AX, 1— (0-<M LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY S JURISDICTION 6 FACILITY 6 TANK 6 STATE I.D.# m = I I I I-T-1-1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST"%GE TANK REGULATIONS FORME (1291) `' �� FORM"