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STATEOFCAUFORMA `/ STATE WATER RESOURCES CONTROL 130ARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B =P , MARK ONLY COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ONE REM ❑ [17] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 2 INTERIM PERMIT E34 AMENDED PERMIT ❑ PERMANENTLY CLOSED ONSITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 TEMPORARY TANK CLOSURE � e TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.t �� C. DATE INSTALLED(MO/DAYA'EAR) 6. MANUFACTURED BV: D. TANK CAPACITY IN GALLONS: ,v — II.TANK CONTENTS FA-715MARKED,COMPLETEITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT C ❑ tb P EMUM 4 GASAHOL ❑ 6 AVIATION GAS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ OTHEq (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E C.A.& A, TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ W OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE E—] 7,ALUMINUM (PdmaryTank) E] g BRONZE ❑ 8 100% METHANOL COMPATIBLE W/FgP ❑ 10 GALVANIZED STEEL �5 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑ 8 UNLINED B5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ gg OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 4:5-71 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©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 8 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 {�T 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTIRITITIAL MONMORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL 7 VES ❑ 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTYo JURISDICTION# FACILffYk TAE STATE I.D.# PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 0_-�r 9 FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. //�p�ppp7�/{