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:e°"aces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDAb 00 a ° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B a� � 0 • C�IIfOA N.� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY E!Kr 1 NEW PERMIT O 3 RENEWAL PERMIT FORMATION ❑ 7 PERMANENTLY MLO 'ITE ONE ITEM ED2 INTERIM PERMIT F74 AMENDED PERMIT 716 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (cl ` .� gFocj /SIG r I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# .S I B. MANUFACTURED BY: ^ n(XA)V C. DATE INSTALLED(MO/DAYNEAR) 9, D. TANK CAPACITY IN GALLONS:: fDOCA 1 11.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. u 1aREGULAR 3 DIESEL ❑ 6 AVIATION GAS A. 4 GASAHOL 2 PETROLEUM F780 EMPTY ❑ 1 PRODUCT ❑ lbUNLEADM ❑ 5 JET FUEL El7 METHANOL N ❑ 3 CHEMICAL PRODUCT ❑ 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.# III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM k-2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL Gl 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 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 JK 6 UNLINED ❑ 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 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(D SINGLE WALL A U 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(2>5 UNKNOWN A U 99 OTHER D. LEAK DETECTION IR-1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTIRSTIIIAL MONITORING [D 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEFlo / I n �, ^��'2 2 i}Sa DA� (PRINTED d SIGNATURE) (1 L �,/- I V LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 13� f a (o 6 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE y/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH TOCAL AGENCY IMPLEMENTING THE UNDERGROUND°-'`#TANK REGULATIONS 4 FORM 8 (12-91) FOR0034BA6-R6