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a s� y f PtSouaces co * : STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD w v UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B �. .I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. a3 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED y ONE ITEM 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE '8 TANK REMOVED � 2 INTERIM PERMIT ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1/ 00 74 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) t,oyL D. TANK CAPACITY IN GALLONS: c 3 ILTANK CONTENTS IFA-1 IS MARKED,CO LETEITEMC. A. REGULAR 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL , ❑ 2 PETROLEUM ❑ 80 EMPTY ��2 PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN W'.AjjSTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED WQj�[, 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 ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRIP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER j ❑ 1 RUBBER LINED �❑ 2 ALKYD LINING E] 3 EPDXY LINING E::] 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO i 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 U 3 GRAVITY A U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE t B. CONSTRUCTION 1 SIGLE WALL A U 2 NDOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER ti C. MATERIAL AND 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 k PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHERI FAL v* D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3(MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITOR ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E:] 91 NONE ❑ 95 UNKNOWN "w 99 OTHER e. VI.TANK CLOSURE INFORMATION I.ESTIMATEDD T OAST D(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO # SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ke-c I D d,3 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH °.LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST E TANK REGULATIONS FORM 8 (12.97 r ,,• 1�"' OR00346 R6 J F - ' ,.e }' :: :.... -...ra ��q',1•-s'^ "4 ...a� �.,.a.- - �!� rte.. _� I��