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r ��f,/{�6I' STATE OF CALIFORNIA p, STATE WATER RESOURCES CONTROL B 1" p, R�3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BN COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. Q MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑❑ 5 CHANGE OF INFORMATION I� y PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 (10 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y B. MANUFACTURED BY: C f„N, C. DATE INSTALLED(MODAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUELOIL B. 0, TA REGULAR UNLEADED 3 DIESEL 8 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT 1D PREMNM UNLEADED � [:]M GASAHOL ❑ 7 METHANOL 1C MIDGRADE UNLEADED 5 JET FUEL ❑ B MSS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 IEADED 99 OTHER(DESCRIBE N ITEM D.BELOMT D. IF(A1)ISNOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.A: 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 R� 2 SINGLE WALL ❑ e SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ,CJ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP Ph"ToN ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ ! PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPA LE WITH 107% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 6 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL, SPILL CONTAINMENTINSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) atr DROP TUBE YES_ NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UN DEFK ND BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U G AVT' A U / FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A_ "1 SINGLE WALL A U 2 DOUBLE WALL V 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 6 FIBERGLASS PIPE CORROSION C-T-S ALUMINUM A U 8 CONCRETE A U 7 STEEL WICOATING 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 1 MEC=Rm LME LEAK 2 LME TRIIRF53 3 CdRW WS MFAST E]4=C UI.E 5 AVf01MTC PV1D D. LEAK DETECTION ❑ oETecroR ❑ tEs1M9 ❑ N011TpIM3 LTA[oErEOTaA 9An9oxH ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 TANK RECONCILIATIONANUAL ORY 113 M�TORING ❑ZE ` GAUGING C TANK ❑ 5 MON TORING7ER E:]8 TESTIANNUNG ❑ 7 MON TOR U INTERSTITIAL ❑ B SIR E:] 9 TANK GAM TAGING EKLY ❑10 MOTESTINGHLY TANK 95 UNKNOWN E]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST UAW 9 AYNR) 2.ESTIMATED OUANI TY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS 1NERTMATERIAL7 THIS FORM S BEEN&MPLETED UNDER PENALTY OF PERJURY,AD TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C RRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION 8 FACILITY M TANK 0 STATE LD:# p p p y 3 PERMIT NUMBER PERMIT APPROVED BY/DATE '\I , L{'IZ15 PERMIT EXPIRATION DATE µ �3 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF""OERGROUND STORAGE TANK REGULATIONS FORM B (695) _