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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD `'-•,• V UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B '. 1 oC COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT c-`•u^ ONE ITEM ❑ 2 INTERIM PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /d o 7 s. Azo vrw I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.6 O 1. MANUFACTURED BY: u CEoola]E . DATE INSTALLED(MOIDAY/YEAR) 1.[ II.TANK CONTENTS IFA-i IS MARKED,COMPLETEITEMC. A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. 1a REGULAR 2 PETROLEUM 0. ❑ UNLEADED =GASAHOL 6 AVLATIONGAS ❑ 00 EMPTY 1 PRODUCT 17 PR M3 CHEMICAL PRODUCT ❑ 95 UNIOJOWN ❑ 2 WABTE EAOED 7 METHANOLLEADED IN ITEM 0. BELOW)D. IF(A.i)ISNOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8 AND C.AND ALL THAT APPLIES IN BOX D ANDS A. TYPE OF ❑ 1 LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 WALL ❑ 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimWT6nk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING3 EPDXY LINING C.INTERIOR ❑ ❑ 4 PHENOLIC LINING LINING ❑ 5 MUSS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 18 LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES- NO- D.CORROSION ED POLYETHYLENE WRAP [:] 2 NO 1:13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTITECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLEAIFABOVEGROU NDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U I SUCTION A A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A I 99 OTHER C. MATERIAL AND A U 1 RE 9 A U 2 STAINLESS STEEL A'U3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATINO PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIONA U 9 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN p U 99 OTHER - D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONrtoRING ❑ V.TANK LEAK DETECTION 99 OTHER ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION E 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 NTERSDTIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3 WITH 4 SUBSTANCE REMAINING 3.WAS TANK FILLED 2� a 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 IMNTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY A TANK 6 STATE LD.# 3 y ETT1 3 S 3cT2ol� PERMIT NUMBER PERMIT APPROVED BriOATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST SE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.