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STATEOFCAUFORNA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BS1 COMPLETE A SEPARATE FORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT a TEMPORARY TANK CLOSURE 8 TANK REMOVED Ci DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p C` I v I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN G A. OWNER'S TANK I.D.# lap B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-I ISMARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ IaREGULARUNLEA ED �❑"7 3 DIESEL ❑ e AVIATIONGAS r72 PETROLEUM a 80 EMPTY ❑ 1 PR0DUCT ❑ 1b PREMIUM 4 GASA40L ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 5 JET FUEL ❑ 2 LEADED99 OTHER (DESCRIBE IN ITEM D. BELOWI D. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED o�/ 1 C III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHATAPPLIES IN BOXD A. TYPE OF ❑ >w WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER �/ ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING s PHENOLIC LINING LINING ❑ C.INTERIOR ❑ 5 GLASS LINING �NLINED ❑ � UNKNOWN ❑ ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D%METHAN0L? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 81 NONE gS UNKNOWN ❑ 99 OTHER IV,PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I 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 BASE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE2MG ❑ O ❑IN 99 OTHER V.TANK LEAK DETECTION MONITORING ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL] YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SiGN�TURE) DATE �r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 00_3 STATE I.D.# a 3 s © *ou j PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROWILF11 -- V /