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e�oAe STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD +` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 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 �6 TANK REMOVED O DBAOR FACILITY NAME WHERE TANK IS INSTALLED: $0 S. k 'oo C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MD/DAY/YEAR) D. TANK CAPACITY IN GALLONS: J500 II.TANK WNTENTS IFA-IISMARKED,COMPLETE ITEM C. UM o A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C ❑ 18REGULARUNLEADED ❑ 4 GASAHOL 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY lyY-nJ 1 PRODUCT ❑ 1hIPREEADD ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE V LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOXD A. TYPE OF DOUBLE WALL F] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2_!!OGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER Fle'l BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 06 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE HATH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP Q 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 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 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 6 CONCRETE A U 7 STEEL WI 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 ERSTITIAL D. LEAK DETECTION [:7] 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING IMMONITORING O W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[7] 4 AUTOMATIC TANK GAUGING E:] 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING r-17 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER-5f VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYA'R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRIMED 6 SIGNAL REI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 8 / I I I I 1� F3d powio/o PERMITNUMBER PERMIT APPROVED BY/DATE -EE9MK-GXPIRAi1GULAiL �. C. FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0611IA/