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�... SPATE OF CAl1FORNA STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B �e `�tsONN� COMPLETE A SEPARATE FORM FORE TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ETr5 CHANGE OF INFORMATION ❑ 7 PERMANENTL CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qe'l A/ , Qj-Oli,dLJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED AY/YEAR) u�, D. TANK CAPACITY IN GALLONS: II.TANK TENTS IFA-11SMARKED.COMPLETE REM C. 1 MOTOR VEHICLE FUEL ❑ 6 OIL S, C, ❑ 1aUNGULARD 8 3 DIESEL ❑ 6 AVIATION GAS A. O 2 PETROLEUM ❑ 80 EMPTY 1 PROIXICT ❑ 1b IUM 6 GASAHOL ❑ 7 METHANOL NLEADE ET ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE 2 LEADED D ❑ 99 JOTHER L(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF Q 1 UBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL F—] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE e POLYVINYL CHLORIDE ❑ 7 ALUMINUM D 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING C.INTERIOR F75 GLASS LINING LINING 6 UNLINED 96 UNKNOWN [j99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING F-] 3 VINYL WRAP E::] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE O 96 UNKNOWN O 99 OTHER IV.PIPING INFORMATION RCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U Sucr A u 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 STEELW/COATING A U 8 10D% METHANOL COMPATIBLENFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTERSTITIAL ❑ 99 OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 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 SUBSTANCE REMAININGGALLONS 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.