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... STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE ONE ITEM U 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZL)S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ 1 WG - B. MANUFACTURED BY: a�•X�iS C. DATE INSTALLED(MO/DAYNEAR) 7/.q:irD. TANK CAPACITY IN GALLONS: IZ DOD II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 19 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 3 JETFUEL ❑ B MBS ❑ 3 CHEMIGALPRODUCT ❑ 83 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEO ❑ 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: 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 [ yI 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 ❑ /0 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 [7 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X NO- ,}y D.EXTERIOR ❑ 1 POLYETHYLENE WRAP E:] 2 COATING E] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE VES NO STRIKER PLATE VES 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AJ92 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 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 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 I MEcWM ME IEAI{ 2 UK n6InKM ��77II 3 wN UWS IN1E9511nAL 4 BECIKONC UK I�5 AMOMAM N- ® DET wm ® TE w a41 MONT9BIN9 IFAK 9ETEMDrt SHV190WN ❑ 89 OTHER V.TANK LEAK DETECTION VADOZE �� ® 1 VISUAL CHECK ❑ 2 RECONCIIATIONANUAL ORY ❑ 3 MONITORING IKI 4 GAUGING AUTOMNTIC TANK ❑5 MONITORINGROUND G ❑e TE�NGTANK ® 7 MON TOR U INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MOTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER G TESNG 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 YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMEwtr.J DATE PRINTE0a 61 gTURET � � /� n LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION M FACIUTY II TANK Al STATE I.D.# 1 151 Ij 1119 N @A n 46 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA' -FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOP RUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL.AN�THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UI�,aROUND STORAGE TANK REGULATIONS. L7 7/NI,j FORMB (6.95) I`�' bV