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• eou- SPATEOFCALIFORNIA �^ STATE WATER RESOURCES CONTROL BOARD W m v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �,o , 'C-4.pN-,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATON n 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE 288 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: �, �. A. OWNER'S TANK I.D.# C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: V ILTANKCONTENTS IFA-11SMARKED,COMPLETEITEM C. aREGULAR 3 DIESEL g AVIATION GAS ❑ 1 OTOR VEHICLE FUEL ❑ 4 OIL B. C- ❑ UNLEADED ❑ A 4 GASOHOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 6iov UNKNOWN ❑ 2 `HASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III, TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A R-AND C.AND ALL THAT APPLIES IN BOX ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC S. TANK 5 CONCRETE ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (PfimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING n 3f�'OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%MET14ANOL7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A&I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. A U 3 LINED TRENCH A5 UNKNOWN A U 99 OTHER CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL C. MATERIAL AND NYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVI M A U g CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP CORROSION A U 5 ALUMINU PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION p l) 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION -11 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNEBS TESTING ❑ 3 I,PERS R IA ❑99 OTHER V.TANK LEAK DETECTION //// ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION F] 3 VAPOR MONITORINGUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ g TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED 6 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PERMITNUMBER I PERMIT APPROVED BY/DATEPERMITEXPIRATION DATE . I FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.