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. STATE OFCAUFORNA •``�.•.; c, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B ve COMPLETE A SEPARATE FORM FOR TANK SYSTEM. `'r•a•••' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT /'S CHANCE OF INFORMATION 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE /CLOSED ONSITE OBA OR FACILITY NAME WHERE TANK IS INSTALLED: Iva /0. ccn u Ugh I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i / B. MANUFACTURED BY: (�lL C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED,COMPLETEITEM C. A. ❑ 1 MOTOR VEHICLE FUEL V A OIL YE:] C. ❑ la REGI ED e 3 DIESEL S AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTYRODUCT ❑ tb PREMIUM a GASAHIOL ❑ 7 METHANOL Ed❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWNASTE UNLEADED 5 JET.FUEL❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN / 1 SYSTEM ❑ 2 OLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ©'99 OTHER Z-IU"W S. TANK -1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ gp OTHER ❑ 1 RUBBER LINED ❑ 2 LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING C.IN ❑ 5 GLASS LINING 8 UNLINED LINING ❑ 96 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING [1] 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC (� 91 PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑ 99 OTHER IV,PIPING INFORMATION CIRCLE A IF ABOVE GROUNDOR U IF UNDERGROUND,80TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY LA Lq"(G}ticqw B. CONSTRUCTION A U 3 GLE "'LL--1 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 6 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATING A U 9 100% 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 7 IN RS UL ❑ MON70RING ❑ 96 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ��NONE ❑ 95 UNKNOWN ❑ 99 OTHER i VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �C�)/J GALLONS INERT MATER �7 YES V NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COR CT APPLICANT'S NAME PRINTED 8 SIGNATURE) ---7— CT ATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW R--�—� STATE I01 COUNTY III JURISDICTION# FACILITY III TANK T N 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROM43-RA