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STATEOFCAUFORNA a STATE 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 PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED:sHu. Ktr S I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN Ks A. OWNER'S TANK I.D.4 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYA'EAR) ' D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. �y1f V A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. [ UNLEADED 3 DIESEL EINITEM TION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �-PRODUCT 1b PREMIUM 4 GASAHOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED ❑ 5 JET FUEL ANOL99 OTHER (DESCD. BEL01V) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC.AND ALLTHAT APPLIES INBOX D AND 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 B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ISI 8 100. METHANOL COMPATIBLE WIFRP (PrimaryTAA4) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING I� 5 GLASS LINING ❑ 6 UNLINED ❑ ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X NO— 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AdDz PRESSURE A U 3 GRAVITY A u oa OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 96 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 PROTECTION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING AVe 100% METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 00 OTHER D. LEAK DETECTION 4 i AUTOMATIC LINE LEAK DETECTOR F] 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE J❑�95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE L S SED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1 SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ N0 � THIS FORM kfAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME 1.(nRINiEoasAru ,/ - DAT__ E -30- 'y-p LOCAL AGENCY USE ONLY THE STATE J.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# J;URISDICTTTIOON�N# FACILITY# 6 TANK#00 STATE LDA# o as S 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. LFORM 8 (12-91) FILE THIS FORM WITH WAL AGENCY IMPLEMENTING THE UNDERGROUND SIVE TANK REGULATIONS FOAO911iR1