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Ou-c' STATE OF CALIFORNIA hp pts' " STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a • CSI RO�N.� , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL O ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �'8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qi V I K, STD? m 42 Ic� 41-z f I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # , i r ' B. MANUFACTURED BY: xIE (2 -XE S C. DATE INSTALLED(MO/DAYNEAR) list D. TANK CAPACITY IN GALLONS: /0'000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL ED 2 PETROLEUM ❑ 80 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN B. �1 PRODUCT ❑ 2 WASTE C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 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 F7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ( 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 F-]5 GLASS LINING F-]6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YE NO— D. EXTERIOR F--11 POLYETHYLENE WRAP ❑ 2 COATING F73 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE I ,�mayy,, I I7l�1B5 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED (YEAR) 0 1 OVERFILL PRE VENTION 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 Ac' '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 AD 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 r 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC UNE ❑ 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN J TAAII, 1 CAI, nCTC/`TIAKI VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR)Q 2. ESTIMATED QUANTITY OF �^' 3. WAS TANK FILLED WITH RMATERIAL?YES I—1 NO n ' SUBSTANCE REMAINING GALLONS INERT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED & SIGNATURE) AA I Kf ) FFXlj j ✓1 LOCAL AGENCY USE ONLY F THE(SSTTATTE BER IS COMPOSED OF THE FOUR NUMBERS BELOW V COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ❑ANNUAL 1 VISUAL CHECK ❑ 7 MONITORING INTERSTITIAL ❑ E:]8 2MANUAL RECONCILII TIIONVENTORY SIR ❑ 3 MONITORING 4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 9 TANK WEEKLY MANUAL [--]10 MONTESTHLY TANK ❑ 95 UNKNOWN j � TESTINGTANK E:]99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR)Q 2. ESTIMATED QUANTITY OF �^' 3. WAS TANK FILLED WITH RMATERIAL?YES I—1 NO n ' SUBSTANCE REMAINING GALLONS INERT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED & SIGNATURE) AA I Kf ) FFXlj j ✓1 LOCAL AGENCY USE ONLY F THE(SSTTATTE BER IS COMPOSED OF THE FOUR NUMBERS BELOW V COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU TION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FW C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TFWRGROUND STORAGE TANK REGULATIONS FORM B (6-95) 0