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it un ee STATE OFCALIFORNIA ;.' °1, STATE WATER RESOURCES CONTROL BOARD s` ,r.. UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c�`��°°�1� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL NSITE ONE ITEM F-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANNK CLOSURE e TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ISA (&Y 006, IY' lr', �1SC S*A - 1. TANKDESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# )A B. MANUFACTURED BY: uKb C. DATE INSTALLED(MO/DAYNEAR) JAU D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEMC. �/ A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.TF1 C. �c 1aUNLEADED REGULAR ❑ 3 DIESEL ❑�� 6 AVIATION GAS ❑ 2 PETROLEUM ❑ W EMPTY DUCT UNEAIDED ❑ 5 JETFUELAHOL ] METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN TE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 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.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 2 SINGLE WALL F-14 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER I B. TANK K_I 1 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 W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ,}❑.J 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING JQ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING r IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ E::]� 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-1 a(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 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AU 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AID 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 STEELW/COATING A U 8 100% 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 ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0 MONRORMG ❑ 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 ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY F 3.WAS TANK FILLED WITH YES ❑ NO� SUBSTANCE REMAI G GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED 1UNDER PENALTY OF P RJURY,AND//��T -THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICAN(PRINTED 8 SIG AATU E) /M i1 � '1 ,(1 / A, I , DATF�_`f_ 7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS CO OSEO OF THE FOUR NUMBERS BELOW if COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED SYIDATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. _ FOR00348-RS