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• aC STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD i� + UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B • ++� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 'Opo. 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 ® 88�TfANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Waterloo Food & Fue C7-,?..;?- (� L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: 000 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY Q 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ED is MIDGRADE UNLEADED ❑ 5 JET FUEL F-18 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Leaded Gaso1ine 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 A 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK r l 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009. METHANOL COMPATIBLE W/FRP (Pr'MaryT-k) ❑ 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 100%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 E.SPILL AND OVERFILL etc, SPILL CONTAINMENT INSTALLS R) OVERFILL PREVENPMENT INSTALLED(YEAR) + DROP TUBE YES NO IKE PLATE YES NOTI OUIDISPENSER CONTAINMENrN20P NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A W 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 A5 ALUMINUM A U 6 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 U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL ULEAKNE 2 LINE T4 ELECTRONIC LINE 5 AUTOMATIC PUMP DETECTOR ❑ TIGHTNESS 3 CONTINUOUS INTERSTITIAL TESTING ❑ MONITORING © LEAK DETECTOR ❑ SHUTDOWN ® 99 OTHER--K0lP V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CILIANUAL TITIONORY ❑ 3 MONITORING ZE ❑ 4 AUTOMATGAUGING IC TANK ❑5 MONITORINGTER ❑6 TESTINGTANK ❑ 7 MONITORCONTINUOUS ITERSTITIAL El SIR ❑ 9 TANK GAUGING ❑10 MONTITNHLY TANK ❑ 95 UNKNOWN F-199 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH Unknown SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANQ TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE) l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ReC- COUNTY# JURISDICTION# FACILITY# TANK# d� STATE IBMm PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION 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 FORMS(6-95) SHOULD BE ACCOMPANIED BY A PLOT RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS f-,/l.0 e F 9 '�/a{ Y 11 �J