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UM p STATEOFCAUFORIA �pcb `i STATE WATER RESOURCES CONTROL BOARD {� - UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B �� :e gid; . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ©/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I S S S p I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# S. MANUFACTURED BY: C. DATE INSTALLEO(MOtDAY/YEAR) C� 7 S D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS ISMARKED,COMPLETEITUW— X A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aUN UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ m EMPTY 1 PRODUCT EE::] 1DREGULAR UN EAIDUM ED ❑ 5 JETFUEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE E::] 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED eL-S/-r- C.A.S.6: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DO LE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) E::] 99 OTHER B. TANK ffl,1 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 (PrimuyTmk) ❑ 9 BRONZE ❑ 10 GALVAN17ED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 kjlZ LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIIOR F-15 GLASS LINING 'BUNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINIS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSK)N ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Fa 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUNk%H IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2PRESSURE U I 3 GRAVITY A U OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 9 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 S LW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECT!ONK V,95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 V CHECK2 INVENTORY RECONCILIATION E] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBS UB STANCE REMAINING GALLONS 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 DATE (PRINTED 8 SIGNATURE] LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ,pEtZIc15 STATE I.D.# ' pcl I I I I I S 6 I I IS 1 61611c? 3 PERMIT NUMBER PMIT APPROVED BY/DATE ERPERMIT EXPIRATION DATE/G FORM 8 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED../� /G