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STATEOFCAUFORNIA n_ STATE WATER RESOURCES CONTROL BOARD s ?tea UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION C:] 7 PERMANENTLY CLO ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT �!rl: TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,j t +n Cflit I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.a B. MANUFACTURED BY: � C. DATE INSTALLED(MO/OAYIYEAR) S'� 0.TANK CAPACITY IN GALLONS:ZolJv`) II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A t MOTOR VEHICLE FUEL ❑ 4 OILB. / C. taUNL.EA ED REGULAR 3 DIESEL ❑ 6 AVIATION GAS �L—yJ( 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lbPR DED 5 JET FUEL ❑ 7 METHANOL ❑I 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S a 111. TANK CONSTRU T10N MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (V LTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE � 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 ijpOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1001% METHANOL? YES_ NO D.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING aL 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 AQ 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(9 1 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 VW COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 0)95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC UNE LEAK DETECTOR 2 LINE TIGHTNESS To ❑ 3 MONRORING ❑99 OTHER V.TANK LEAK DETECTION F71 VISUAL CHECK 7 2 INVENTORY RECONCILIATION E] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑TANK TESTING ❑ 7 INTERSTITIAL MONITORING L✓ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAYNR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 1 NO i SUBSTANCE REMAINING GALLONS ❑ INERTMATERtAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED E SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW NZ 9 3�y7 C COUNTY# JURISDICTION# FACILITY# TANK# I STATE I.D.# ,07 I Z O PERMIT NUMBER I PERMIT APPROVED BY/DjATE PERMIT EXPIRATION DATE / 2 ,/ J /t THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �',,i ,lA� FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ""ll ECRM 8 (12-91) • . FOROOW8-R6