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• STATEOFCAUFORMAON STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM BCOMPLETE A SEPARATE FORM FOR EdH TANK SYSTEM. MARK ONLY r; I NEW PERMIT ❑ 1 RENEWAL PERMIT 5 CHANGE OF INFORMATION C T PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ s AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: , rI ✓-e- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.a S. MANUFACTURED BY: ,r//io/ C. DATE INST ED(MOIDAWYEAR) C' 0. TANK CAPACITY IN GALLONS: ('_' 0 II.TANK Q&TENTS IFA-1ISMARKED.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ A OIL a. C a REGULAR �OIESEJ'/ 6 AVIATION GAS UNLEADED `GI'SAi.O LJ ❑ 2 PETROLEUM ❑ a0 EMPTY / PRODUCT i lb PREMIUM '� A L T METHANOL ❑= u J S CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED 5 JETF�EL 2 LEADED 99 OTHER (DESCRIBE IN ITEM O. BELOW 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF L I DOUBLE WALL ❑ S SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL I� 2 STAINLESS STEEL '`❑ 0 FIBERGLASS ❑ A STEELCLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL --71 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE j❑ 7 ALUMINUM 8 100% METHANCL COMPATISLEWIFRP (Primary Tank) ❑ 9 SRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN j;; 0 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING u 7 :?OXY LINING r A PHENOLIC LINING O INTERIOR LINING I—: 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 98 OTHER ITIS--LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION LJ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION (,❑ 91 NONE n 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV,PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 0 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 7 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/CRATING A U 8 100% METHANOL COMPATIBLE WXRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICP90TECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONBORNG ❑ 99 OTHER V.TANK LEAK DETECTION ' 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 0 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING L 5 GROUND WATER MONITORING I� 8 TANK TESTING ❑ ] INTERSTRIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION L ESTIMATED OATS T USED(_ AV/VR) 2.ESTIMATED QUANTITY OF ].WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONSI INERT MATERIAL? YES ❑ ND❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME ( INTED a SIGNATURE? DATE LL q LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY% JURISD�ICTIONI x FACILITY It TANK STATE I.D.# � j, 1—I— I -cc lial O I(/ PERMIT NUMBER PERMIT APPROVED BYIDATE -!--�-�I PERMIT EXPIRATION DATE FORM 8 (?-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoROmt&R5