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STATE OFCALIFORMA •Feoo+ e. STATE WATER RESOURCES CONTROL BOARD =� c� UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B `� 'so ., o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - •�4�nOnn�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ ❑ 7 PERMANENTLY CLOSED ON SITE 6 TEMPORARY TANK CLOSURE a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFYIFUNKNOWN T A. OWNERS TANK I.D.0 off. B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) E�7� D. TANK CAPACITY IN GALLONS: ONS: IFA-11S MARKED,COMPLETE ITEM C. A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. FT 1a1gNLpO 3 DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ e0 EMPTY 1 PRO16 PREMIUM 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WAS'Nit UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. III IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPIL BOX DANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN ,{• 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B, TANK I7K 1 BARE STEEL ❑ 2 STAINLESS STEEL 0 3 FIBERGLASS !/�—^ ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (P#meryTAnk) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LININ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL YES_ NO— D.CORROSION El1 POLYETHYLENE WRAP 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 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 IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UN04OWN A U 99 OTHER C. MATERIAL AND A70 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION AT 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE WiFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U g9 OTHER D. LEAK DETECTION E 1 AUTOMATIC LINE LEAK DETECTOfl 2 LINE TX3HTNESS TESTING ❑ MONITORING ❑� OTHER V.TANK LEAK DETECTION R 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 97 NONE ❑ 95 UNKNOWN O 98 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U D(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:j NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ReG D .23 a.3 ( (o COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® (o PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) �/1 46