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C /I o..." BTATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY C E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE rg TANK REMOVE lllJll DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z��l S / _4 y/n� J^ _ ❑ 9 100% METHANOL COMPATIBLE W/FRP I. Ie•nnvWVT1Ir 11VIY COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # �t / B. MANUFACTURED BY: O C. DATE INSTALLED (MO/DAYNEAR) LS D. TANK CAPACITY IN GALLONS: Q/ 00 II.TANKCONnNTS IFA.IISMAR Fn Cnuol[ Prtn.n A. L!1"1 --MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1AREGULAD ❑ 3 DIESEL ❑ g AVIATION GAS E:]2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL 2 E�rl BARE STEEL ❑ 2 STAINLESS STEEL ❑ LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. N : III. IANK CUNSIHUCTION A. TYPE OF❑, 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L � 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK E�rl BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (PNmeryTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 10 CATHODIC PROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— LEAK DETECTION D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ��5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. YIYINU IN rUHMA I IUN CIRCLE A IPARnVPr,9nUNnnR D mT.Inc RO°IH CR, o A. SYSTEM TYPE A 1 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 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 g CONCRETE A U 7 STEEL W/ COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONITORING V. TANK I FAK nFTFY`TInM ❑ 1 VISUAL CHECK '2 INVENTORY RECONCILIATION ❑ 3 yADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING [V 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE O 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGF IS Talk 4,vn rnaacrT APPLICANTS NAME (PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE LD. NUMBER IS COMPOSED OFTHE FOUR NUMRFRs RFI nW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMITNUMSER PERMITAPPROVED BY/DATE PERMIT EXPIRATIONDAT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) 10 0 FOROM4&R6