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'`ya+�cea • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3y' UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Waterloo Food & Fuel I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.# B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. Q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ ib PREMIUM UNLEADED Q 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 1c MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOVV) 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.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F❑-} 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM L_t} 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (P"MaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 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 1000/6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ® 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER SPILL D E.SPILL AND OVERFILL,LKC. DROP TUBE AY SENT INSTANO R) STRIKER PLATE YES FILL PR NO OX_ D SPENSERMENTLLED CONTAINMENT YES NO_ 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 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A(V 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MEO M�ICAL LME LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTRIft 4 MECMMC UK 5 Au1OMILnC PUMP ❑ DETECTOR ❑ TESTING ❑ MOMTORING E] LOX DETECTOR F-1SHUTDOVYN ® 99 OTHER N r)n e V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RE p CILIATIONAL ORY ❑ 3 MAODNIITORING OZE F-] 4 GAUL NG AUTOMATIC TANK ❑5 MON TORINGGROUND TER ❑ 6 TESTINGANNUAL ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY GAUGANGAL ❑10 TESTING Y TANK E:395 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO Unknown SUBSTAGE REMAINING S 5 O GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR , O THE BEST OFAWKNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED S SIGNATURE) Keith A. Tallia-A ent 9/27/99 Of LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW . k 3 COUNTY# JURISDICTION# FACILITY# TANK# � STATE I.D:# j�l15 V)I Sr 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 PLAN. THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNBOUND STORAGE TANK REGULATIONS FORM B (6-95) Q _^ 3 / 3®,a Q /Jn