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IY�I�Y STATI OF CAUFORNIA �� s STATE WATER RESOURCES CONTROL BOARD C , ➢i UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BW, fr~ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY �k, 2 NEW PERMIT 77, 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON _ ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT,\ ❑ E TEMPORARY TANK CLOSURE n 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK{0,0 l ( � B. MANUFACTURED BY: Q LlJ P h U CI C. DATE INSTALLED(MO/DAY/YEA (, l D. TANK CAPACITY IN GALLONS: I-000 II.TANK CONTENTS IFA-1 IS ARKED,COMPLETEITEMC. A PS;�;1 MOTOR VEHICLE FUEL ❑ 4 OIL - B. C. ❑ to REGU UNLEADED" 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ib PREMIUM' 4 GASAHOL ❑- 7 METHANOL ❑ ❑ ❑ ❑ UNLEADED ❑ 99 JET DTHERFUEL (DESCRIBE IN ITEM D. BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALLTHAT APPLIES IN BOX D AND E fes/ A. TYPE OF Lru 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN . SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE n 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WlFRP (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKY9 LINING ❑ 31EPDXY-LINING L Q 4/PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS LINING ® 6, UNLINED! = ❑ 95:UNKNOWN X89 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES X NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ,�5 9 y OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 01 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)AO 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°i 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 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ® 1 AL 99 OTHER MONII ORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ,\J 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION i.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E] NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME J DATE (PRINTED d SIGNATURE) y�L !� ��• _ t� � 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER-iSICOMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTfON# r FACILITY# TANK# STATE I.D.# I .l PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATIOrrDATE------- THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE_UNDERGROUND STORAGE TANK REGULATIONS 1 FORM B (12-91 -r f J kyr S C( e 'J 4 y FOR00348R6 1