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� � • wF°°u4 es c 1 P 1. STATE OF CALIFORNIA = o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B °�t1f011 N\ /r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE MARK ONLY O 1 NEW PERMIT ❑ g TEMPORARY TANK CLOSURE 8 TANK REMOVED Q ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT DBA OR FACILITYNAMEWHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN S. MANUFACTURED BY: A. OWNER'S TANK I.D.• .fY -_ __ /]_ D. TANK CAPACITY IN GALLONS: ` a C. DATE INSTALLED(MO/DAY/VEAR) Ul%- — II.TANNNKKCCONTENTS IFA-1 IS MARKED,COMPLETEITEM C. 4REGU AR 3 DIESEL ❑ 8 AVIATIONGAS A. VJ" MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ UNLEADED 4 GASAHOL PRODUCT ib PREMIUM ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B.AND C,AND ALLTHAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN rAN q SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER yJ��2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP K5 CONCRETE❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ g9 OTHER ❑ 1 RUBBER LINED ❑ 22 ALKYD LINING ❑ 3 EPDXY L ❑LINING 4 PHENOLIC LINING ` C.INTERIOR ❑ 5 GLASS LINING ]�L 8 UNLINED E] 95 UNKNOWN ❑ 99 OTHER LINING /--� IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— [:] 1 O_❑ 1 POLYETHYLENE WRAP 7c2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION `g1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 9B OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A�U j3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE Alm STEELW/COATING A U B 10096 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOW, A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ HER 1 VISUAL CHECK IJSI 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 55 GROUND WATER MONITORING ❑ 6 TANK TESTING/❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? 1.ESTIMATED DATE LAST USED(MO/DAYIVR) SUBSTANCE REMAINING TH)S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRiNTEDb SIGNATURE) 3 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW e4:Z, TANK# COUNTY# JURISDICTION# FACILITY# STATE I.D.# L�� L a PERMIT NUMBER PERMIT APPROVED BY/DATE PERM IT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WRSLOCAL AGENCY IMPLEMENTING THE UNDERGROUND STT�AGE TANK REGULATIONS(; FORM 8 (12-91) -7 3`'1 - 7 _J OR00366R6