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rGspun;Pe c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B W A a . a 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 F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QZ7:1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.41 B. MANUFACTURED BY: C. DATE INSTALLED{MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL g, C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT1b PREMIUM ❑ 4 GASAHOL ❑ UNLEADED ❑ ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 2 WASTE 5 JETFUFL ❑ UNKNOWN ❑ ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(AA)IS NOT MARKED„ ENTER NAME OF SUBSTA CE STORED C. Ill. TANK CONSTRUCTION MARK ONE ITEM ON IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ ❑ ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 ECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STA LESS STEEL [:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLY INYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWIFRP (Primary Tank) 9 BRONZE ❑ io GALVA IZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD U ING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.IN LINAG ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHA L 7 YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 6 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION C2RCLE A IFABOVEGROUNDOR U IFUNDER OUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U7TRENCH A I 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL U A U 95 UNKNOWN A U 99 OTHER C, MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A ULORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A TING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIONOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE T)GHTNES TESTING 3 I �y MONITORING I_I 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER A TANK CLOSURE INFORMATION 1,fiSTI ATI DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH _I SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO �J THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE 1S TRUE AND CORRECT APPLICANTS NAME {PRINTED 8 SPGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE 1,D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW " STATE 04COUNTY# JURISDICTION# FACILITY# TANK# � =/ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 io-A(�-�0-� �18 r