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. Tei.`"v47?" ^... raa.... y, - .. ,..., _ ....,.... .,, ... ... .:., ♦. ,:. . . . ._ .a. �. _ .G<:. STATE OF CALIFORNIAa STATE WATER RESOURCES CONTROL BOARD �le- UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BgZSIy� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT III�II��❑"'��''��8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.I S. MANUFACTURED BY: C DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: O O 11.TANK CONTENTS I, IF A•1 IS MARKED.COMPLETE ITEM C. tPEGULw UNLEADED 8 AVIATION GAS A 1 MOTOR VEHIC EL ❑ d OIL A C. o 3 DIESEL ❑ F-1 2 PETROLEUM ❑ 80 EMPTY I7IV PRODUCT IE PREMIUM UNlE10m 6 GASAHOL ❑ ] METHANOL /" 1c MDCRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM O.BELOW) D. IF(A1)IS NOT MARKED, ENTER N E OF SUBSTAGE STORED C.A.S.x III. TANK CONSTRUCTION ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL2 STAINLESS STEEL F73 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ a 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2%UNED ING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS UMNG ❑ 8 ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH ACL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PFlOTECTON ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL, SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) etc. DROP TUBE YES_ NO_ STRIKER UTE YES NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDENVOLIND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U Z DOUBLE WALL A U UNED 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 LYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U ] WICOATINO A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IEOUMf.N.IeIE LEAK ❑2 uIE TMKRFaS 3 CMIIMWa NTFA9IIML ❑d UNE ❑s AUr01MnG mw ❑ 99 OTHER oElEcroR TFSTaxi Moxraartq 9MmowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANRECONAL CILIATION CILIATIONORY ❑ 3 VADOZE MONITORING ❑ ` AUTOMATI GAUGING MONITORING ❑ 5 GROUND WATER MONITORINGF7ANNUAL TANK 8 TESnNG ❑ 7 COMTOROU INTERSTITIAL [:18 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLYT ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST U ED( YNR) 2.ESTIMATED QUANTITY OF lWASTAWRIIEDWITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INET TERIAL7 THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d SIGNATURE) l LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 2G MD A 3 1 T" STATE I.D:# COUNTY X JURISDICTION R FACILITY X TANK k PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP''-`TION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ---M C MUST BE COMPLETED FOR INSTALLATIONS. IS FORM SHOULD BE ACCOMPANIED BY A PLOT RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TI -iGROUND STORAGE TANK REGULATIONS FORM B (8-85) -t-) ' / / , 46