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r • STATE OF CALIFORNIA • ^r'�4 4 r c`': STATE WATER RESOURCES CONTROL BOARD �.--` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =:� ; � "° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT F73 RENEWAL PERMIT F75 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED CBA OR FACILITY NAME WHERE TANK IS INSTALLED: t A 1,q Ll S I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# I,t„v,,, too - B. MANUFACTURED BY: ;WAr-i e )1 n C. DATE INSTALLED(MO/DAYNEAR) 419h D. TANK CAPACITY IN GALLONS: II.TANK('ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. �-� A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. REGULAR 3 DIESEL ❑ 1a UNLEADED 6 AVIATION GAS 4 GASAHOL - PETROLEUM ❑ 80 EMPTY X1 PRODUCT a 1b PREMIUM �', 7 MCTHANOL UNLEADED ❑ 5 JETFUEL - -1 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN n 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) J. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E r- A NPE OF >< DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER S. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL __�'' 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100°i METHANOL COMPATIBLE WFRP iP,lirary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER y 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ��❑//4 PHENOLIC ING i `" i I ERIOR 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER !_NING --- - --- IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ �.CURROSIOfJ --- 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ IV. PiP!NG INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE [—A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Ao 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 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 U 95 UNKNO A U 99 OTHERO&AJ/ rlS2� D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING FA3 INIERST111A MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION 1VISUAL CHECK 1 2 INVENTORY RECONCILIATION F7 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING j 6 TANK TESTING t7 INTERSTITIAL MONITORING El 91 NONE E:] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME AjjtDV tit DATE/ (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# DDq STATE I,D,# IF 17p16 11D PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-115