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STATE OF CALIFORNIA • 7 (2 ^� "� `-_ STATE WATER RESOURCES CONTROL BOARD sy o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Vd o' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 7 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ M AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE � B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS NSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK LD.A S. MANUFACTURED BY: C. DATE INSTALLED(MOIOAY(YEAR) 0. TANK CAPACITY IN GALLONS: a II.TANK ACOONTENTS FA-I IS MARKED.COMPLETE ITEM C. A. y-1 MOTOR VEHICLE FUEL ❑ a OIL g, C la REGULAR S DIESEL ❑ S AVIATION� UNLEADED a GASAHOL F I 2 PETROLEUM ❑ 90 EMPTY I PRODUCT ❑ iE PREMNM ❑ ❑ 7 METHANOL jJ 0 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 a 5 JET FUEL 0 99 OTHER (DESCRIBE IN ITEM D. sELOwI 0. '!F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.A: III. TANK CONSTRUCTION MARK ONE ITEUCNLY INSOXES A B.ANOC.ANOALL 7HATAPgLIES IN BOX A. TYPE OF ❑ I DOUBLE 'WALL ❑ S SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER S. TANK ❑ I SAFE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ A STEEL CLAD W/F18ERGLA33 REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM a nBLE WI (P6muy Tani) I❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E 95 uNLNOWN O ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3,ZPDXY LINING { LINING C.INTERIOR —f 5 GLASS LINING B UNLINED 9S UNKNOWN ❑ 99 OTHER LINING _J LS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_�J�VAMMNNO_ 0.CORROSION ❑ I POLYETHYLENE 'WRAP ❑ 2 COATING ❑ WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 9p OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IFUNDERGROUNO.BOTHIFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER I`,AV1 B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 7 POLYVUJVL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATINO A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 2 GALVANIZED STEEL A U 10 CATHCOIC PROTECTION A U 95 UNW40WN A U 99 OTHER 0. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINETIGHTNESSTESTUW ❑ MONROR9q ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 5 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGM ❑ 5 GROUND WATER MONITORING NS TANK TESTING ❑ 7 INTERSTmALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIOAYNR) ( 2.ESTIMATED QUANTITY OF 1 WAS TANK FRLEO WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPUCANrS NAMEDATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ' l �STATE I.D. COUNTY 7 JURISDICTION 7 A TANK R S ® o a PERMIT NUMBER �'/ PERMIT APPROV Y T RMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOAXIMikU o