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STATE OF CALIFORNIA '-••"� 1, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BD� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �lJl7 G �E I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# e B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) , D. TANK CAPACITY IN GALLONS: 0 LDa ILTANK NTENTS IFA-11SMARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 9, C to REGULAR 3 DIESEL ❑ 6 AVIATION GAS A. UNLEADED 4 GASAHOL ❑ 2 PETROLEUM C! SO EMPTY 1 PRODUCT 10 PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ED95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEDD ❑ 99,ETOTHERL(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.W: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 UBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 21�1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ B BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2,11ekYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING6 UNLINED ❑ 95 UNKNOWN O 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(PEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A f t SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 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 6 CONCRETE A U 7 STEEL VW COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Aa[�15 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING ❑ 3PTERSTITIA MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION 7��— y�GAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTRIALMONRORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO C; SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#3cI7 TANK#00 STATE I.D.# IN [dKl 13 LC1,S_I;z�610 13 1 PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE f--r FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.