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STATE OF CAUFORNIA '`��°"••5` STATE WATER RESOURCES CONTROL BOARD ey M1' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �' m 1 � o' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED d DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QAp 5. o4le- 1. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N V-11-- S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) v— D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 1b PREMIUM UNLEADED �4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(AA)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 UNER ❑ 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION —y PROTECTION ❑ 5 CATHODIC PROTECTION IJ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTIO UIPMENT INSTALLED(YEAR) DROPTUBE YES NO STRIKER PLATE YES_ NO CIS PENSERCONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER 8. CONSTRUCTION 01 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 02 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% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑❑1 MECWIM IME LPAK 2 ME MWNESS 3=IIIWWS rN ST 4 ELECTRONIC UK 5 AU10PUMP ❑ DETECroR TEsIlw MOMTORING ❑ LEAK DETECTOR ❑ sHUiM4TC m E] 99 OM41M V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 MAODOZE NIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 6 TESTTANK TESTING ❑ 7 CONTINUOUS MONITORING TANK ❑ 8 SIR E] 9 TANEK GAUGINGAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PUCE) 1.ESTIMATED DATE LAST USED O/DAYNA) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO SUBSTANCE REMAINING Z!> 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# FACILITY TANK# j STATE I.D.# 0 3�zs�q PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUQI�Q0N-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95)