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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ' '"o .'c�b UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BC A 3" e COMPLETE A SEPARATE FORM FOR EANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M O I B. MANUFACTURED BY: UN K C. DATE INSTALLED(MO/DAY/YEAR) U D. TANK CAPACITY IN GALLONS: OO II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGUTAR UNLEADED3 DIESEL ❑ 6 AVIATION GAS ❑ 1 PRODUCT ❑ 10 PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM E] 80 EMPTY ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.If: 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 DqUBLr WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM [DM 95 UNIC40 SYSTEM GLE 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 (PNm#ry Teak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED Fp�g5 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 ATMG ❑ 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECDON91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLC. SPILL CONTAINMENT INSTALLED(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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION U 3 SINGLE WALL A U 2 DOUBLE WALL A U 3 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 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100-A METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(D5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHMIIGAL LINE I-AK 2 ME RGWNESS ON 3 CONTINUOUS INTERSRIIAL 4 EIFCIROMC UNE 5 ARC PUMP IXJE=R ❑ TESRNO MOMTORNG LEAN DETECTOR ❑ UEOMA SHUIGOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ORY ❑ 3 MODNIITORING OZE ❑ 4 GAUGING AUTOMATIC AUG NGIC TANK ❑5 MONITORINGGROUND TER ❑8 TEST NGTANK ❑ 7 CONTINUMONITORU INTERSTITIAL El SIR ❑ 9 TANK WEEKLY MANUAL E:]10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ED NO 1:1SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# TANK# STATE 04COUNTY Z 3 1171 11 (o p 12 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE %N I L , ; THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUrATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR_M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TV IDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) `P 140/