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`w STATE OF CALIFORNIA %n/ STATE WATER RESOURCES CONTROL BOARD syd�, - _ e e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O B TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qp ,L . L�cko/ Ave _ Z cwo I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: v C. DATE INSTALLED(MOIDAY/YEAR), D. TANK CAPACITY IN GALLONS: c) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL E] 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICALPROWCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Ai)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 ❑ 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 ❑ 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 UNED ❑ 2 ALKYD LININGKam 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F--) 5 GLASS LINING E::] 6 UNLINED 1/ 1 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? EESS— NO— D.EXTERIOR O 1 POLYETHYLENE WRAP ❑ 2 COATINGVINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUSE YES NO_ STRIKERPLATE 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 A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 'd/V 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 SaFA.)W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECNWIIG UNE UM 2 ME TIGESS CDNTI 3 NUWS IWERSmAL T 4 EU:=NC UNE 5 AWOTMTID WAP DETECTOR ❑ WN TESTNI MONTORNG LEAK DETECTOR O SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILATIONANUAL INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING TANK ❑5 GROUND MONITORING ❑ 6 ANNUALTESTING ❑ 7 MONITORINGINTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL ❑ 10 MOTESNTHLY TANK 95 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ 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 (PRINTEO 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION k FACILITY a 10 TANK M rD STATE I.D.# Ui FT-171 p p 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 PLAY -".E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U✓ 'GROUND STORAGE TANK REGULATIONS FORM B (6-95) va� NaOF FOR09N&117