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SPATE OF CAUFORMA .•� •••••; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B : COMPLETE A SEPARATE FORM FOR EA TAMC SYSTEM. c•`'"�"" MARK ONLY ENrNEW PERMIT ❑ 3 RENEWAL PERMIT 17FV15 CHANGE OF 1NFORMATgN ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT rl 8 TEMPORARY TANK CLOSURE ❑ 8 TAMC DBA OR FACWTY N WHER£TANK IS WALLED: „�f,(r_• 1. TANK DESCRIPTION COMPLETE ALL ITEMS— sPECB=Y IF umo om A. OWNERS TANK 1.D.s S. MANUFACTURED BY: C.DATE INSTALLED(MCVOAYMEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 Bsm^mmD coMPLETEITEMC. A ❑ 1 MOTOR VEHICLE FUEL ❑ a O8. B, C ❑ Ia UNLEADED �u� 3 DIESEL ;"T 8 AVIATION GAS i❑ 2 PETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM ,�-� A GASAHOL �❑ 7 METHANOL (❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LD ST FUEL ❑ n OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: IR. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.s.AND c.AND ALL THAT APPLES IN BOX 0 AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANIQ ❑ N OTHER 8. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ l STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM I❑ 8 IW%METHANOL COMPATIBLE W/FRP (Primvy Tx*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 ue*om ❑ w OTHER ❑ 1 RUBBER U ❑ 2 ALKYD LINING 1❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C.IN NINE ❑ ED S GLASS LINING ❑ 8 UNLINED ❑ 9S UNKNOWN ❑ 98 OTHER IS LNNG MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ 0.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATMKG ❑ 3 VINYL WRAPL—j a FEERGLASS RENFORCED PLAS-nC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NOW ❑95 LRW40WN ❑ 99 OTHER E SPILL.AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDEAGROU ND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 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 U 95 UNI(NOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINL.ESs S A U 3 POLYVINYL CHLORIDE(PVC)A U a FUWJ40LASS PIPE CORROSION A U S MAIM A U a CONCRETE A U 7 STEELWMCOATWO A U 9 100%METHANOL COMPATIBLE WIFRP PROTECTION A U GALVANIZED STEEL A U 10 CA PROTECTION A U 95 UNIKNOWN A U 90 OTHER O. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TKGFITNESS TESTING ❑ ❑pp OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCLLIATION ❑ 3 VADOZE MONITORING ❑ a AUTOMATIC TANK GAUGING NO WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 9S UNKNOWNSIP 98 OTIGER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOCAMM 2.ESTIMATED QUANTITY OF 3.WAS TANK FILM WITH I SUBSTANCE REMANI G GALLONS INERT MATERIAL 7 YES ❑ No❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (PFWaM 8 SKIMMAS LOCAL AGENCY USE ONLY THE STATE LD.NUMBER LS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURtSD CTKMI s FACILITY t TANK r STATE I.D. PERMIT NUMBER i PERMIT APPROVED BYiOATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM T HAS BEgN EKED. i S�G17/ mom