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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B J .d, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT C; 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT CI 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QCZ (�+; \'C (D31 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.o 3 B. MANUFACTURED BY: �S C. DATE INSTALLED(MO/DAY/YEAR) 0. TANK CAPACITY IN GALLONS: O U U II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A X 1 MOTOR VEHICLE FUEL 4 OILB, C. 'a REGULAR UNLEADED 3 DIESEL _J 6 AVIATION GAS 2 PETROLEUM 80 EMPTY i 1 PRODUCT 1 15 PR"EWUM CNLEAOEO 4 GASAHOL 7 METHANOL J tc WOGRADE UNLEADED 5 JET FUEL 8 M65 3 CHEMICAL PRODUCT 95 UNKNOWN2 WASTE 2 LEADED �! 99 OTHER(DESCRIBE IV ITEtd D.SELOt;1 0. IF(A.1)IS NOT MARKED. ENTER NAME OP SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.9,AND C.AND ALL THAT APPLIES I\BOX D AND E A. TYPE OF K 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNO?lN SYSTEMt❑� 2 SINGLE WALL F74 SINGLE WALL IN A VAULT 99 OTHER L_- B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE Q 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL ` I 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY UNING 4 PHENOLIC LINING LINING OR 5 GLASS LINING ® 6 UNLINED 1—, —1 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X— NO_ D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP ; 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNO'NN 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) iAIN L OVERFILL pREVENT;ON ECUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,CtC, DROP TUBE YES X _. NO STRIKER PLATE YES X 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&2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 WI 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 1 MECHANICAL LINE LEAK2 uNE T15MNm 3 ccfmhU0U5 UrTERSrmAL 4 ELECTRONIC U.`E 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION ® OETECTOR [:] TESTING MCH Ci:ING ❑ LckK=E=R vumovw L] V.TANK LEAK DETECTION '—� 2MANUAL INVENTORY i 3 VADOZE 4 AUTOMATIC TANK I1- 5 GRCUND WATER 6 ANNUAL TANK 1 VISUAL CHECK RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 CONTINUOUS TANK INTERSTITIAL 8 SIR ❑ 9 LY MANT UAL 10 MONTHLY TANK J 95 UNKNOWN 99 OTHER ON VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED C.ATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY CF 3.WAS TANK FiLLED'NITH YES = NO SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ^ 1 DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE\I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS FLOW COUNTY# JURISDICTION a FACILITY a TANK# STATE I.D.# W �� PERMIT NUMBER PERMIT APPROVED BYlCATE 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6951