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1 9 fgOUNCfS STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD 3� g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ,1 3 COMPLETE A SEPARATE FORM FO EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT*11-6TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU I Zo P I' Ag-LAFT I2 I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # I ?-I — 3 B. MANUFACTURED BY: )(F_:� 5 C. DATE INSTALLED(MO/DAYNEAR) q 8 D. TANK CAPACITY IN GALLONS: O00 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. PK -1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1�9_1 PRODUCT �1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM 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 DOUBLE WALL F-]3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [:]95 UNKNOWN SYSTEM �❑.__, /1 'r 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 �9�5/UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESLS NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP V4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 01'� "5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL EtC. SPILL CONTAINMENT + DROP TUBE YES STALLED (YEAR) OVERFILL EVENTION EQUIPMENT INSTALLED (YEAR) " 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 AG)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ ❑ ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK OETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ZE 1 VISUAL CHECK En 2 MANUALINVENTORECONCILIATION RY ❑ 3 MONVADITORING 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 6 ANNUALTESTING ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY GAUGING TESTING ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) , 1 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH IV SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PE TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE N (PRINTED 6 SIGNATURE] � f '/ � / E'K'( A /j/lnd kI )©ter,.jt4 LOCAL AGENCY USE ONLY THE STATE I.D-I0MBER IS COWOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I. Dl ® 3 1141-5 V PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE � THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEqpRGROUND STORAGE TANK REGULATIONS FORM B (6-95)