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STATE OF CALIFORNIA °s . P STATE WATER RESOURCES CONTROL BOARD 3 , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BCl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z �W q f�/ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a cl-�-) 3 B. MANUFACTURED BY: ,,-/1 ,1 5 C. DATE INSTALLED(MO/DAY/YEAR) /f 6 S D. TANK CAPACITY IN GALLONS: QQv II.TANK CONT IFA-1 IS MARKED,COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL g. C ❑ 1a REGULAR R ❑ 3 DIESEL ❑ 6 AVIATION GAS A F-] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT rf 1b PREMIUM ❑ 4 GASAHOL 7 METHANOL UNLEADED ❑ 5 JET FUEL 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED 99 OTHER DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# Ill. 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 F-1 3 SINGLE WALL WITH EXTERIOR LINER E�:] 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK 1 BARE STEEL F--] 2 STAINLESS STEEL F7 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F-] 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 1009/6 METHANOL COMPATIBLE W/FRP (Primary Tank) a 9 BRONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR Q 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP F7 2 COATING F-] 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION [:] 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1009/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(!t;� UNKNOWN A U 99 OTHER D. LEAK DETECTION L;;J� TOMATIC LINE LEAK DETECTORLINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING �SOMATIC TANK GAUGING [::] 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#1 TANK# WAA) � STATE I.D.# � J 111 q 1-31 91la5l PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 1 z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.0 1pel�— // / (' FORO B-RS