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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W �8 <br /> Vii.. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.4 B. MANUFACTURED BY: n <br /> C. DATE INSTALLED(MO(DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANK ENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL O 6 OIL8. C• 1aREGULAR NLEA�O UNLEADED `�' 3 DIESEL 5 JETFUEL 6 AVIATIONGAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 1b PREMIUM u 4 �SAHOL O7 METHANOL <br /> U [] <br /> 3 CHEMICAL PRODUCT DS UNKNOWN 0 2 WASTE O 2 LEADED 99 OTHER (SCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,B.ANDC,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF F-1 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER E::] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL F--] 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 0 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED F-� 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR F-] 5 GLASS LINING F7 8 UNLINED F-] 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION D 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTKN Q 91 NONE O95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 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 <br /> C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING <br /> 0 MONITORINGTITAL O 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING F-] 7 INTERSTITIAL MONITORING 0 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY x JURISDICTION# FACILITY x TANK p <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1,31 FORM B (12-91) - 1� I FOROONBR6 <br /> jai *40f �/� <br />