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STATE OF CALIFORNA ` STATE WATER RESOURCES CONTROL BOARD s'y UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B .ice "° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION \E::] 7 PERMANENTLY CLOSED ON SITE ONE REM F72 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Hyl 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J"'� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I'D a 6. MANUFACTURED BY: l( C. DATE INSTALLED(MODAYIYEAR) D. TANK CAPACITY IN GALLONS: V d ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL �B. C. I*REG UNLEADED B 3 DIESEL ❑ g AVIATX7N GAS ULAR F-12 PETROLEUM ❑ SO EMPTY �laC 1 PRODUCT ❑ 70 PREMIUM 4 GASAHOL ❑ 7 METHANOLC� UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.,)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.6: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALLTHAT APPLIES IN BOXO AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 154.2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PdmaryTwk) ❑ 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 ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE '-Td 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR OVERFILL PREVENTION EOUIPMENT INSTALLED(YEA IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A i 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 TRENCH0'1/6UNKNOWN A U 90 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 STE L W/COATING A U B 10D% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑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 F-17 INTERSTITIAL MONITORING ❑ 91 NONE 5EyI95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM DATE LAS 5 D(MOIDAV/v R) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUB STANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF M KNOWLEDGE, IS TRUE AND CORRECT (A�PPLI�CA��NS5�+"�N"�AME VIA/J b ,1 �,,/ DATE` LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 6 FACILITY 9 TANK# STATE I.D.# m = I 1 1 171= 8 3 O PERMIT NUMBER PERMIT APPROVED BYIDATE 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 TI+'-')CAL AGENCY IMPLEMENTING THE UNDERGROUND STOP -E TANK REGULATIONS FORM 8 (12-91) `w 1-.01, FORG9M846