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STATE OF CALIFORNIA J �� STATE WATER RESOURCES CONTROL BOARD i - "� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "sa r�„t '`A �� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c1 �� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SmTFI ONE ITEM L:7 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: , C. DATE INSTALLED(MO/DAV�R) v D. TANK CAPACITY IN GALLONS: f 000 II.TANK CONTENTS IFA-IISMARKED,COMPLETE ITEM C. A �..i—MQTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ LUNGEUNLEAAR ❑ 4 DIESELGASAHL O 8 AVIATIONGAS O 2 PETROLEUM ❑ W EMPTY �TRODUCT ❑�/1^b PREMIIUMNLEADE ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN � 2 WASTE ,L 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,5,ANDC,AND ALLTHAT APPLIES IN BOXD AND E / r, — A. TYPE OF ❑ 1 DOUBLE WALL D 3 SINGLE WALL WITH EXTERIOR LINER o-� UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER O1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE B. TANK ❑ 8 POLYVINYL CHLORIDE ❑ 7��MINUM O 8 190% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER O 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 NVL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 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 1 SUCTION A U 2 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 A 5 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 S ALUMINUM A U 5 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AU OMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST D(MO/DAV/VR) 2. SUBISTANCE REMAIN)GF a GALLONS 3ESTMATED QUANTITY WA INERT MATERIAL)?TANK FILLED WTH YES [:] G ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (iRINTED 8 SIGNATUFEI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE I.Dl (� PERMIT NUMBER PERMIT APPROVED BYIDATE TEXPIRATK)N DAT r /� G j T FORM 8 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAN FILED. T F 1