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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3y a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ( DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU(,(1! 5ToP M400LL-_ 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# 1-2-) — 2- S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) MA-2c q [q 4$ D. TANK CAPACITY IN GALLONS: Z 00.0 II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. f,53-1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY �1 PRODUCT nrib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.K: III. TANK CONSTR-UCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E Ag A. TYPE OF 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 PE�r43 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE W/FRP (P"Mary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHE14OUC LINING LINING OR ❑ 5 GLASS LINING rK 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES,2� NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING I❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E] 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BtC. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) 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 A-0 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AD 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)04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODI PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [-]' MECNANICAL UNE LEAK ❑2 UNE TKHMSS 3 CONTwuoLs anEAST M ❑4 ELECIRONIC UNE 5 AUTOMATIC PUMP ❑99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUMOM V.TANK LEAK DETECTION ❑ VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL MONITORING ❑ 3 MONITORING ZE 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGER ❑6 TESN'TIINGTANK MON WRONUS G INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER G TESTING i VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED NTH SUBSTANCE REMAINING GAI-1-0317S INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PE TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 6 SIGNATURE) t � KE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 1.4 1.31 11 H 13 101 1.510 17 R6 z 3 z 99 PERMIT NUMBER �2 3 &() PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FgW MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GAOUND STORAGE TANK REGULATIONS FORM B (6-95) A �///��y