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W.w '"of <Fy0U9 <. <br /> STATE OF CALIFORNIA <' <br /> STATE WATER RESOURCES CONTROL BOARD i4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B m "° <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT TS< 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /r <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: �j D �p GO/o J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.0 V , K I <br /> B. MANUFACTURED BY: <br /> C. DATE INSTALLED NO/DAY/YEAR) 15-1 D. TANK CAPACITY IN GALLONS: 1011, <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A O 1 MOTOR VEHICLE FUEL �4 OIL B. C. ❑ 1sUNLEADED REGULAR 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM 80 EMPTY O 1 PRODUCT 0 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED Q 5 JETFUEL <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL E�l 4 SECONDARY CONTAINMENT (VAULTED TANK) 1 99 OTHER <br /> B. TANK D 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE F7 8 POLYVINYL CHLORIDE k 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) E] 9 BRONZE 0 10 GALVANIZED STEEL 85 UNKNOWN 0 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING E 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING O 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION O I POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION Q 91 NONE (}�95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) -rte OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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<9�:05 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 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 8 CONCRETE A U 7 STTE�EE--LA�W`/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Adrk UNKNOWN A U 9,99 IOTHER y <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING Q 3 MONRTITIl ka99 OTHER TiORING <br /> • ,K <br /> V.TANK LEAK DETECTION <br /> ED 1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING E:] 91 NONE 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 <br /> SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 YES O NOO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AAPPLICANTS NAME DATE <br /> PBINTEO851G.ATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW T"1_ -9 T 35q <br /> COUNTY# JURISDICTION# L TANK x <br /> STATE I.D.# 3 E= o0 /E <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 /> FORM 8 (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> a t`��-1 FORO¢41BR6 <br />