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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B P , °ano ry,. COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ITE MARK ONLY ONE ITEM EJ2 INTERIM PERMIT ❑ 4 AMENDED PERMIT `l ❑ a TEMPORARY TANK CLOSURE ❑ e TANK REMOVED Z_ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L{ D"( W) I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK LD.% �/ B. MANUFACTURED BY: dA �� C. DATE INSTALLED(MOIOAVA'EAR) D. TANK CAPACITY IN GALLONS: Q(, d II.TANKCO S IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR ❑ 3 DIESEL ❑ e AVIATION GAS A UNLEADED PREMIUM _j 4 GASAHOL ❑ 2 PETROLEUM ❑ BD EMPTY i PRODUCT ❑ 10UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ gg 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 F-] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANIQ ❑ 99 OTHER F-11 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ s CONCRETE (PrimaryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �9 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 9s UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE el 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(ek UNKNOWN A U 99 OTHER 0. LEAK DETECTION OMATIC LINE LEAK DETECTOR [a-I'LINE TIGHTNESS TESTING ❑ 3MCNRORING E9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMAD QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB STANTECE REMAINING GALLONS I ❑ NERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It FACILITY# TANK# STATE I.D.# fKF9 Z 7 b / b l fl 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIPN§ FORM 8 (12-91) � � �� FOR0814B116