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0 • oo+ + STATE OF CALIFORMA `., STATE WATER RESOURCES CONTROL BOARD sy 2 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�"� 'tee COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �+"'O""�� MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT r-15 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S dd Fk. (A1 EAA E e *I D N A fLI rb 0 rlt. 17L/ ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) — 1. ININR VCJMOIr IIVI'1 COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.11 /0,1- u B. MANUFACTURED BY: D E• /, l FZoU- C. DATE INSTALLED (MO/DAYNEAR) //- L/,f D. TANK CAPACITY IN GALLONS: O DAN/ IL TANK CONTENTS IF A.usueRKFn rnuPl PTF rt#uc A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑D 1AUEG AR NLEADED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY ® 1 PRODUCT ❑ IOPREMIUM A GASAHOL El 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ ❑ 2 LEADED ❑ 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: III. TANK CONSTRUCTION MARK ONE ITEM CN[ Y IN ROYFS A R ANOC AMI All THAT APPI FS IN RnYn A.1P A. TYPE OF ® I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS © 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER D. ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING © 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES _ NO— D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER p ` E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) S IV. PIPING INFORMATION CIRCLE AIFAROVFGROIINDORLIIFIIMIFPfRMINORnTHIEAPPIIP.ARIF A. SYSTEM TYPE A U 1 SUCTION A g2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AID 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 8 CONCRETE A U ID CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE S 10D% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ]kj 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 NOTEING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ® 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER 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 YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT Em LUUAL AUtNUY USt UNLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION # FACILITY If TANK# STATE I.D.# m Li -i -j ist 0 15ly 1( S o Is"I 8 Ll8 PERMIT NUMBER PERMIT APPROVED BY/DATE PERM IT 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 THOCAL AGENCY IMPLEMENTING THE UNDERGROUND STO## TANK REGULATIONS FORM 8 (1291) FOR90H8%