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STATE OF CAUFORMA a STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT C:] 8 TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:_2 I,c�-p - SPECIFY S lJ I. TANK DESCRIPTION COMPLETE ALL ITEMSY IF UNKNOWN A OWNERS TANK I.D.# OL/ B. MANUFACTURED BY: C. DATE INSTALLED(MNDAV/YEM) 0. TANK CAPACITY W GALLONS: E/E(E�OEEE]II.TANK NTENTS IFA4 ISAIARIED.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ laURNEGULAD 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 8D EMPTY 1 PRODUCT ❑ to PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 90 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.*: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B.AND C.AND ALL THATAPPLIES INBOX0 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ ❑ 95 UNKNOWN SYSTEM �/2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK IV 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmMyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LWWG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LININGS UNLINED LINING ❑ ❑ ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION O 91 NONE ❑96 UN104OWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 90 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 CATHOOICPROTECTKJN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0 I ❑ 92 OTHER MONRORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONRORWG ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA LAST USED(MO/DAY/YfU 2.ESTIMATED WANTITY OF 3.WAS TANK FILLED WITH Z SUBSTANCE REMAINING GALLONS INERTMATERIALT VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PPoHTED a 91GHATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# � � /��/ �/) �(�� '/�v..;IL � PERMIT NUMBER PERMIT APPROVED BY/DATE1-F-J pERMH-Ei(P1ihF71B1FBMa 3 �'�'- r/ FORM 8 (949q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. G /�� FOROW43R1