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tr " 0 STATE OF CALIFORNIA °"••, STATE WATER RESOURCES CONTROL BOARD "4 UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM Bb, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ® 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C. ki e t o l 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.e ` B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) Vq80 D. TANK CAPACITY IN GALLONS: 500 II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ® 4 OIL B. C. to REGULAR UNLEADED3 DIESEL E] 6 AVIATION GAS ® lb P ED H 4 GASAHOL E] 7 METHANOL 2 UM ❑ 80 EMPTY ' ❑ 1 PRODUCT � ® tc 5 JET FUEL ❑ B M85 ® 3 CH CT ® 95 UNKNOWN 2 WASTE ` ❑ 2 LEADED 99 OTHER(DESCRIBE IN CfEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ s WTERNAL MADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ® 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® 8 10D%METHANOL COMPATIBLE w/FRP Tank) ❑ 9 BRONZE 10 GALVANIZED"STEEL ❑ 95 UNKNOWN ® 99 OTHER C.INTERIOR ❑ i RUBBER LINED ® 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH t METHANOL? YES_ NO— D.EXTERIOR ® 1 POLYETHYLENE WRAP ® 2 COATING ® 3 VINYL WRAP 4,FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 0 91 NONE ❑95 UNKNOWN ® 99 OTHER E SPILL D OYERFIL SPILL CONTAINMENT STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES No STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U ` DOUBLE WALL A U 3 UNED 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) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100%METHANOL COMPATIBLE w/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN ON - A U 99 OTHER D. LEAK DETECTION ®1mEOOMCAL UNC LW ❑2 UNC 3 co�mnwa is WrERSTrm a N LE t ®5 AUTOMATIC N EDN OTHER TES17N6 MONT�NO OPAL NCTa1SIMIXIM V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 M UALIIINAVEE®OORY ❑ 3 MAON�ITORING ® 4 AUTOM GT IC TANK ❑5 MON T GROUND WATER ❑6 ANNUALTESTINTANK 7 CCOON71N000C'S INTERSTITIAL ® 8 SIR ❑ a TANK LAU ANG ❑10 MMONTHTESTIHLLY TANK E] 95 UNKNOWNNITORIN ®9H OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) UANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ® NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ ND OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME m (PRINTED&SIGNATURE) e LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED )F THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D. m F = I- 1-T-1 PERMIT NUMBER 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.FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAor LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE tWUND STORAGE TANK REGULATIONS FORMS(6-95)