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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Iy, . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CiffS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (r 'i- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.A B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) (�l D. TANK CAPACITY IN GALLONS: w II.TANK CONTENTS IFA-11SMARKED,COMP ITEMC. p ❑ 1 MOTOR VEHICLE FUEL A OIL B. C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM Q BO EMPTY ❑ 1 4 GASAHOL T ❑ 1pUNLEADEO 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PROWCT O 95 UNKNOWN 2 WASTE ❑ 2 LEADED W OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(Ai)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.x: III. TANK CONSTRUCTION, MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOK 0 AND E A. TYPE OF ❑ 1 BLE WALL F73 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM Z LE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL F-13 FIBERGLASS O a STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 tao% METHANOL COMPATIBLE WIFPP (PTimuyTm*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ O LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR F-15 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%.METHANOL? YES_ NO— D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 NG 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUtPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 OMVI 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 A FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 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 U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A 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(MOAAYIYR) 2.ESTIMATED OUANTRY OF 3.WAS TANK FILLED WITH YES [::] NO O -5; SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME OATS IPgIRTEO A SKiNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTYx JURISOICTK)Nx FACIL(TVx TAW STATE ��c'vcae'o LD.# 91 FFR j � PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION WTfe_ -/_ q7� FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.