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`-77177-777777; `ypUM°ts STATE OF CALIFORNIA �P r cOa STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 'i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY E!f1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (PV(k. S?oP 7& S I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# f � ' B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) SJ^I �� ' D. TANK CAPACITY IN GALLONS: /Z 00 0 11 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑r. 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 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 E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL [ye3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 7-1/2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING '❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ,/ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT TISTALLED(YEAR) OVERFILLRREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES v NO STRIKER PLATE YES V' NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A49 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 fU? 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 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 A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS �: 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP D. LEAK DETECTION ❑ DETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ANNUAL ❑0,'1 VISUAL CHECK ❑ 2 MANUAL RECONCILIIATIONVENTORY E] 3 MONITORING VADOZE E214 GAUG NGAUTOMATIO TANK E:] 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK ❑ 7 MONITOR CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TWEEKLY ANKGAUGINGAL ❑10 TESTINGMONTHLTANK E—] 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) // 2.ESTIMATED QUANTITY OF ... 3.WAS TANK FILLED WITH YES �/� SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PfNALYOFNRJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED&SIGNATURE)MIK �'"' / DATE � '51X 'IB LOCAL AGENCY USE ONLY THE"STATE I. . BER IS COMPOSED OF THE FOUR NUMBERS BELOW 1;,, I D ok COUNTY# JURISDICTION# FACILITY# TANK# 001 STATE LD.4 jffmI I I -J PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM 8 (6-95) SHOULD BE ACCOMPANIED BY A PLOT PLWC ILE THIS FORM'WITH THE LOCAL AGENCY IMPLEMENTING THE GROUN��D,,,rrrSTORAGE TANK REGULATIONS