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STATE OF CALIFORNIA r `""• °�1 STATE WATER RESOURCES CONTROL BOARD 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 CL SE 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 & Fu2 3_d I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: 51000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. is REGULAR UNLEADED9- 4 3 DIESEL 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O, ❑ ❑ ❑ lb PREMIUM UNLEADED GASAHOL ❑ 7 METHANOL ti § ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT � ❑ 1c MIDGRADE UNLEADED H 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 0 '2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED L@a,ded Gasol 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 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 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 t h (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLICC JNWG LINING OR ' .S GLASS LINING `6 UNLINED 1:195 UNKNOWN ❑ 99 OTHER COATING - 10 UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_:. _.. D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING (D'3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9/ NONE ❑95 UNKNOWN_ ❑ 99 OTHER _ E SPILL AND OVERFILL etcSPILL CONTAINMENT INSTALLED EAR) OVERFILL PREVENTI EQUIPMENT INSTALLED(YEAR) + . DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO ' N.PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WAIL 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`.0 4'FIBERGLASS PIPE CORROSION AAlk�5 ALUMINUM A'U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE'W/FRP� PROTECTION A 9 GALVANIZED STEEL' A U 10 CATHODIC PROTECTION A U 95 UNKNOWN "A U 99 OTHER D. LEAK DETECTION 1 MECHMIICAL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE [ SA UTOMATIC PUMP " - ❑ =C ,�. TESTING MONITORING ❑ LEAK DETECTOR' �'+�;'.'SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION 21 ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND WATEMONITORING R ❑6 ANNUAL TESTINGT 7 CONMON INUO US G INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MO TIN LY TANK ❑ 95 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY,OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,lS TRUE AND CORRECT. ` TANK OWNER'S NAMETrE' ., � DATE (PRINTED a SIGNATURE) kL3 99. 2T—ACT _ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# 77-1 (F PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ON•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.TMFM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH ERGROUND STORAGE TANK REGULATIONS