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STATEOFCALIFOMA ; s STATE WATER RESOURCES CONTROL BOARD i '- UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B C(,0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 9 TANK REMOVED WN DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - u, r.5 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNER'S TANK I.D.A l B. W ACTURED BY: C. DATE INSTALLED(MO'DAYHEAR) V D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-I ISMARKED,COMPLETE ITEM C. J A. EI 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 14 REGUL R 3 DIESEL ❑ 6 AVMTONGAS �1�� 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ lb UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 5gL99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED (J C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.ANDC,AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINERUNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) � 95 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PNmeryTAn%) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNIWOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.W ❑ 5 GLASS LINING LININGINING ❑ 8 UNLINED 95 UNKNOWN E] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) L OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUNG,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A Q95 UNKNOWN A U W OTHER C. MATERIAL AND A U 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 0 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHDDICPROTECTION A(g296 UNKNOWN A U 92 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORINGr-- 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ER 95 UNKNOWN ❑ 90 OTHER VI.TANK CLOSURE INFORMATION 1. STIM TED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES J NO❑ i SUBSTANCE REMAINING CULLONS INERT MATERIAL? F71 ielq THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME D Ai E l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANK 9 DO6 STATE LDAm 1.21,3111D �F 9 D y 6 l IS �7 PERMIT NUMBER PERMIT APPROVED BVIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORME (1291) FILE THIS FORM WITH THE,"' AL AGENCY IMPLEMENTING THE UNDERGROUND STOR'/ TANK REGULATIONS +../ FORWwBq$