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SPATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD i 'o UNDERGROUND STORAGE TANK PERMIT APPLICATION " FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY O SITE ONE REM ❑ 2 INTERN PERMIT ❑ A AMENDED PERMIT O e TEMPORARY TANK CLOSURE ❑ S TANK RE VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z, 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.a q I B. MANUFACTURED BY: C. DATE INSTALLED NOIOAYNEAR) 0. TANK CAPACITY IN GALLONS: u G ILTANKCO TENTS FA•i ISMARKED,COMPLETEITEIMC. A. t MOTOR VEHICLE FUEL ❑ A OIL B. G 2f 1AREGULAR EO 3 DIESEL C e AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY E?-.11"PRODUCT ❑ It,PREMIUM A GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE ❑ 2UNNLLDED A D ❑ 5 JETFUEL ❑ 90 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S a_ III. TANK CONSTRUS20N MARK ONE ITEM ONLY IN BOXES A,&AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ©3 FIBERGLASS ❑ A STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL C14LORIOE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W,4RP (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING � 8 UNLINED ❑ % UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? YES_ ND_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP r FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE % UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUNDORU IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U % 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 a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WT COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOCPRaTECTION A U % UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ I AUTOMATIC UNE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3;OW RORMC ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK �❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING [71"77 7 INTERSTITIAL MONITORING ❑ 9f NONE ❑ % UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIDAYNq) 12 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO`❑ SUBSTANCE REMAINING GALLONS I INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAME IPRINTEG 6 SIGRATURIS DATE 7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY P JURISDICTION P FACILITY a TANK It STATE I.D.# PERMIT NUMBER I PERMIT APPROVED BYIDATE i PERMIT EXPIRATION DATE , THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Lt— FILE FILE THIS FORM WITH TV- `CAL AGENCY IMPLEMENTING THE UNDERGROUND STOF TANK REGULATIONS FORM 9 (1291) FOPOffMb96