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• STATE OF CALIFORNIA D STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY Cn ONE ITEM 112 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [:] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: y C(o-t �'- [-� q !o I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 2� B. MANUFACTURED BY: V (C / D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAV/YEAR) �O ILTANKCONTE IFA-11S MARKED,COMPLETE ITEM C. RE GU AR 3 DIESEL ❑ 6 AVIATIONGAS LIF(A.1)r ❑ 4 OIL B. C. UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 80 EMPTY 1 PRODUCT ❑ 1bNIL ED ❑ 5 JET FUEL ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: F TANK CONSTRUCTION MARKONEITEMONLYINSOXESA.B,ANDC,ANDALLTHATAPPLIESINBOXDANDE ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 96 UNKNOWN F ❑ 4 SECONDARY CONTAINMENT (VAULTED TANYq ❑ 99 OTHERM 2 SINGLE WALL❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC K E] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWIFRP IAL 5 CONCRETE Tank) ❑ 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 6 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHAN0L7 VES_ NO— [::] I O_❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN ❑ 99 OTHER g1 NONE PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 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. SYSTEMTYPE A U 1 SUCTION U 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATOWN A U 991 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A� D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR - 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑ 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 3.WAS TANK FILLED WITH YES ❑ NO ❑ 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF INERT MATERIAL 7 SUBSTANCE REMAINING GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# FT-T] 6 ( G I OZ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE S/^. 'LY^,9y THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOROG I&R6 FORM 8 (12-91) 0 0