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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDy' 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B LL ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANEN LOSED ON TE ONE ITEM ❑ INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK RE VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Charlies Day & Night Lock & Key Service I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.k B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 11,TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A AJC I 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. q C. 1e flEGUWi UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS "❑ 2 PETROLEUM ❑ BO EMPTY 4K 1 PRODUCT ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1O MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ O M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBENTEM0.8ELOV) D. IF(A I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.e III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF Loy I DOUBLE WALL O 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 L� I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 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 ❑ I RUBBER LINED ❑/ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ED95 UNKNOWN E] 99 OTHER E.SPILL AND OVERFILL,BM. SPILL CONTAINMENT I ST LED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES_ 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTIONt IaLaluarAL leaf L IYM M coamAlwa LFA¢ 2 LN3 OnlnT 4 Sla7R NIC UNE 5 AUTO =PIWP ❑ OETECTCR ❑ TE39N6 MONITORING [EAI(pE}E�}pq ❑ gKUI00WN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION NUAL ORY ❑ 3 MONITORING ZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORING GROUND R ❑6 TTEESI ANNUAL 7 CONTOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK GAUGING ❑10 MOSNTHLY TING TANK g5 UNKNOWN ❑ 99 OTHER E] VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING reS1CIUa1GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE URY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTmaSIGNATURE) Charles Skobrak 5/15/97 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER54ELOW COUNTY k JURISDICTION A FACILITY k Cj$ TA STATE LD:# 0 0 D b e PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE'- -RGROUND STORAGE TANK REGULATIONS FORM B (6-95) ...� FORDON& 7