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_ T STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD *MARF--1 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM BCOMPLETE A SEPARATE FORM FOO EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 05 CHANGE OF INFORMATION PERMANENTLY C ED NSITE 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !• O�-/Q.�t . /'O I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# U �� B. MANUFACTURED BY: G �j C. DATE INSTALLED(MO/DAY/YEAR) v, �. D. TANK CAPACITY IN GALLONS: 6�� II.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OILB. C. ❑ to REGULEO ❑ 3 DIESEL ❑ 6 AVIATIONGAS 4 GASAHOL ❑ ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT ❑ 1bUN UNLEADED D ❑ 5 JET FUEL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED Ly 99 OTHER (DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED X a/ C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER NLn: 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL E] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL Ct 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED tfs� 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 VES_ NO_ L K 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(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A05 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ 3 NONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING F 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM.G TE LAS USED(M0/DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH u SUBSTANCE REMAINING GALLONS INERT MATERIAL?j7nelk YES O NO 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# TANK# �r STATE I.D.# Z>/Zv/9 PERMIT NUMBED I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH Tff LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST`RwE TANK REGULATIONS FORMS (12-91) FOR0034 BAS