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�soo. e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °S <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE DL <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: SJ zO A <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN V � <br /> A. OWNER'S TANK I.D.#I17 I T 1 (C' I B. MANUFACTURED BY: O <br /> C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: 0O� <br /> II,TANK CONTENTS IFA-11SMARKED.COMPLETEITEMC. <br /> A. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 18 REGULAR FZ:Z- DIESEL <br /> EGURDIESEL 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT E:71 1b PREMIUMEA4 L O 7 METHANOL <br /> UNLDED � JETFUE <br /> 5 JET FUEL <br /> O 3 CHEMK:ALPRODUCT 0 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN REM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.S: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK J <br /> 1 BARE STEEL O 2 STAINLESS STEEL KI J3 FIBERGLASS E 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> " <br /> MATERIAL 5 CONCRETE 0 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN Q 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 91 NONE O 96 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL AC'1 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION / AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING O 31NTERS MLW OTHER <br /> MONITORING O <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING a 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 7 INTERSTITIAL MONITORING 0 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 YES O NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLK:ANTS NAME DATE <br /> IPRNTEO a SIGNANREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# ® I I I /1/ 15 1�r I I I I I S7zac�r <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> iI <br /> FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> -06Z FORD BM <br />