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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B iyr . COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM F72 INTERIM PERMIT F7 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 60-45 �J I, TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 7 ¢� /-�/$ Al-.) 'Is--37 A. OWNER'S TANK I.D.#jfg:,�JJ- -.-eB. MANUFACTURED BV: I�, C. DATE INSTALLED(MO/DAY/YEAR) I Z D. TANK CAPACITY IN GALLONS: w1 ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A Q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1- FADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM F-] 80 EMPTY F?l1 PRODUCT �lb PREMIUM ❑ d GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. 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,8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF �❑ 11 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN L SYSTEM _ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK lell BARE STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED E 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑�3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E:7] 5 CATHODIC PROTECTION ❑ �91 NONE �°O UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A192 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 0795 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A®95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Z2 LINE TIGHTNESS TESTING El MOTORING ❑99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 1018 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/VR) 2. ESTIMATED QUANTITY OF Q GALLONS 3 WAS TAN MATED WITH YES ❑ NO �" ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, O THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME . 1.#i✓'�O . DATE IP6INTEDaSIGNATURE) L. 1 1,19,p LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED dTHE FOUR NUMBERS BELOW NCOUNTY# JURISDICTION# FACILITY# TANK# STAT D (, L PERMITNUMBE PERMIT APPROVED BY/DATE .1, PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAT LED. a0 FOR09kB