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STATE OF CALIFORNIA quo STATE WATER RESOURCES CONTROL BOARD 4A— MARK UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED -- lt— DBA OR FACILITY NAME WHERE TANK IS INSTALLED: pZZ_ I At tavi,4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNEPS TANK 1.D. B. MANUFACTURED C. DATE INSTALLED(MO•DAYNEAR) D. TANK CAPACITY IN GALLONS: p pC-�> u II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL O 4 OIL B. ,}� C. L] I6 REGULAR UNLEADED O 3 DIESEL 0 6 AVIATIONGAS 2 PETROLEUM O 80 EMPTY XY 1 PRODUCT I_Y'b PREMIUM UNLEADED O 4 GASAHOL 7 METHANOL [$ 1c MIDGRADE UNLEADED O 5 JETFUEL O 8 MB5 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE O 2 LEADED Q 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.M 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 I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR UNER 0 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT O 99 OTHER S. TANK F-] 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F__j 6 POLYVINYL CHLORIDE 0 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PNmery TeDk) D 9 BRONZE O 10 GALVANIZED STEEL [] 95 UNKNOWN 0 99 OTHER C.INTERIOR O I RUBBER LINED 71 2 ALKYD LINING 0 3 EPDXY UNING 04 PHENOUC LINING LINING OR r__j 5 GLASS UNING F__l 6 UNUNEO O VNO_ D. F-199 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES J� NO_ D.EXTERIOR a I POLYETHYLENE WRAP a 2 COATING Ej 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION F 5 CATHODIC PROTECTION Q 91 NONE 95 UNKNOWN 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT I AL LED(YEAR) OVERFILL P VENTION 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 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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 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 ALVANIZED STEEL A U 10 CATHODIC OTECTION A U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION MECHAMCAL ME LTV( O 2 UNE T NESS - CCMINUWS WTERSTIRM O 4 ElEMm UNE 5 AIRCMATC PUMP ❑ 99 OTHER oE1Ec Wl MSnx6 MON1aBN6 LEAN D CTOA sxurWwx V.TANK LEAK DETECTION j/GIBUAL CHECK 2 RECO CIUATIONANUAL ORY O 3 M ZOERING 4 GAUGNGAUTOMATIC TANK 5 MONITORINGGROUND TESTING O 6 ANNUALTESTINGTANK 7 CO MON TOR NG INTERSTITIAL 8 SIR ❑ 9 T NKIGAUGINGAL O IO MONTHLY TANK 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ONO O SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS 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 6 SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# (� p g g PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FP-'I C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE :RGROUND STORAGE TANK REGULATIONS FORM B (6-95) _.o�