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t5o�a c. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B a� <br /> �o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK 0 LY F7 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE` <br /> ONE ITEM F-1 2 INTERIM PERMIT a 4 AMENDED PERMIT Ej 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: NtD L <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# N IJ B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) p D. TANK CAPACITY IN GALLONS: 2,0 om <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. <br /> 1 MOTOR VEHICLE FUEL 4 OIL a. 1a REGULAR 3 DIESEL <br /> C' UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY S4p1 PRODUCT 1b PREMIUM J <br /> 5 ET FUEL <br /> D 4 ET FUELL 7 METHANOL <br /> 3 CHEMICAL PRODUCT UNLEADED <br /> 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 0 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER [:] 95 UNKNOWN <br /> SYSTEM 5d--)2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL [::] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING E 5 GLASS LINING )0�36 UNLINED 7 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP F7 2 COATING F7 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-] 5 CATHODIC PROTECTION 91 NONE E:] 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 0 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(p 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AID 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AID 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING 3 I E IAL <br /> MONITORING [::] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK �2 INVENTORY RECONCILIATION r7 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING � 5 GROUND WATER MONITORING <br /> TANK TESTING 7 INTERSTITIAL MONITORING F-] 91 NONE 95 UNKNOWN F� 99 OTHER <br /> Vi.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LA T USED O/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES 0 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY#1,5 "­— TANK <br /> STATE I.D.# ® 23 ( kof Z <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERM ATION DAT <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM 8 (12-91) . • ,1�� FOR0034B-R6 <br />