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e �Ne P4 C STATE OF CALIFORNIA .e �� STATE WATER RESOURCES CONTROL BOARD a ate, a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ n; V COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM P•°�i,.oe,.�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C-d I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.O.# O B. MANUFACTURED BY: u C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL E::] 4 OIL B. C. ❑ 1a REGUL R 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT E] 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 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.0: III. TANK CONSTRUCTIO MARKONE ITEM ONLY IN BOXES A.B.ANDC,ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ V&UBUE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 RE STEEL ❑ 2 STAINLESS STEEL F--13 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-100 7 ALUMINUM ❑ 8 1 % METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 8a OTHER IV.PIPING INFORMATION CIRCLE IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 trGLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U RE 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 8 100% 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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 ATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE % UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LASTU^YED(MQ/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ((�r/� �� SUBSTANCE REMAINING �GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTEDa SIGN4TURe) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK /Iol i((Tl STATE I.D.# m I als-I's-ILI I I I lb IT PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �j �F090Wa&M