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pURCts STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B " 00 `� _ .: o • C+t IIOP H.r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT If? 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL D SITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU L K 5'o P MAiQ k&7- =0-1Z > FIBERGLASS I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 12-1-1 B. MANUFACTURED BY: xE2XES C. DATE INSTALLED (MO/DAYNEAR) $ D. TANK CAPACITY IN GALLONS: 10 O O p 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 F__] 2 PETROLEUM ❑ 80 EMPTY �'i PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL F-1 8 M85 E::]3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ;K�2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL > FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 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 El99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100'/ METHANOL? YES&( NO— D. EXTERIOR CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE95 ( UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT IN6iALLED (YEAR) OVERFILL EVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, etc. 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 A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL AU 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Ao 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 MVTl MECHANICAL UNE LEAK M 2 UNE TIGHTNESS3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ ❑ [DLEAK E:]99 DETECTOR TESTING MONITORING DETECTOR SHUTDOWN OTHER / TAMV 1 CAI[ nCTCf'TIAKI ❑ANNUAL 1 VISUAL CHECK 2 ECONCILMANUALIIIATIONVENTORY F-]3 MONITORING 4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER 6 TESTINGTANN ❑ 7 MONITOR CONTINUOUS ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MO TINLY TANK E::]95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH LAG n u_n_ I—I ta • 'k. 2. REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PEA4LTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME 0DATE (PRINTEDd SIGNATURE) /J/�' yr J Gs LV /�, LOCAL AGENCY USE ONLY THELSTTAD_ E RR IS CDMPASFn nFTHFEMIR MIIRARFRS RFI nW V c/ COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D:# 12-1;:7,1 i M;u `F & 3 PERMIT NUMBER OERMIT APPROVED B'/DATE PERMIT EXPIRATION DATE q � � 4 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICTION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIWRGROUND STORAGE TANK REGULATIONS FORM B (6-95) 2