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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 0 COMPLETE A SEPARATE FORM FOR EACIi TANK SYSTEM. , MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ Y ONE ITEM ❑ 2 INTERIM PERMIT d AMENDED PERMIT 7 PERMANENTLY CLOSED ON SITE ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: id O S, u-c car w I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.8 L S . ECAPACITY 1RE0 BY: G DATE INSTALLED(MGDAY/YEAq) (` , L C IN GALLONS: ILTANK CONTENTS IFA-IISMARKED,COMPLETE ITEM C. A. IF I 1 MOTOR VEHICLE FUEL ❑ d OIL 8. / C. ❑ 1aUN EA EAR D 3 DIESEL ❑ e AVIATK)N GAS ❑ 2 PETROLEUM ❑ eo EMPTY PRODUCT ❑ lbP M 4 GASAHOL LEADED 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED D. IF(A1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1110UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SLE'/ LE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 3 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPAT18LE W/FRP (Drim4ryTen4) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2LWMG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN r7 W OTHER IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE 95 UNKNOWN ❑ W OTHER E.SPILL AND OVERFlLL SPILL CONTANMENi INSTALLED(YEAR) OVERFILL PREVENTK#J EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIF ABOVE GROUND UNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRE 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 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 a 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 UN N A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ 9D OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 ATIC TANK GAUGING ❑ 5 GROUNO WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(YO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME tPNNTM A SgN RM DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 1.011.01COUNTY# JrnURISDICT�ION# FACILITY# TANK# �T CT kO) 3 y U PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM 8 (7.91) 1HIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS 8EEN FILED.