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V STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD +' ' UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ry- . COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE '❑ 8 TANK REMOV75z DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• Z B. MANUFACTURED BV: // C. DATE INSTALLED(MO/OAYIYEAR) G 0. TANK CAPACITY IN GALLONS: 1171 I� II.TANK 96NTENTS IFA.IISMARKED.COMPLETE ITEM C. tAREGULAR A. 1 MOTOR VEHICLE FUEL ❑ A OIL B. G 7 DIESELUNLEADED ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ tO��DED S JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW D. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 1 L ' R'L C.A S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A&AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CUD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary TNk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNO N ❑ 99 OTHER LINING /'N V IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO W,y x/ D.CORROSK)N ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION r;�/91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUN UNDERGROUND.BOTH IF APPLICABLE A, SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U ] GRAVITY A U 99 OTHER S. CONSTRUCTION A(U 1 SINGLE WA L A U DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU 1 BARE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A F18ERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTION A U 95 UNM40WN A U 99 OTHER INTERSMIAL D. LEAK DETECTION I❑ 1 AUTOMATIC LINE DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ So OTHER V.TANK LEAK DETECTION w ory A 14� ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONITORING ❑ A AUTOMATIC TANK GAUGING GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER 2 VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) ( 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERML? YES ❑ NO'1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPUCANPSNAME DATE IPRIMTEp A 9 WtMNNE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW IZO COUNTY;t JURISDICTION x FACILITY x TANK x STATE I.D., PERMITNUMBER 1 PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) An (1 PoR901BA8