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pU-CF8 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;� g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •CSI iRORN\P COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT. ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED r DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -''I:Grloo Food & F'U2 ._S Q ,}, ,S 1. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) +nknoWn D. TANK CAPACITY IN GALLONS: cJ OOG II.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 El lb PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL F] 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW/) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# IIL 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 rl 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Pq 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 COMPA'BLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER .. C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING n � LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING ll� 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 INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) \ DROP TUBE YES NO STRIKER PLATE YES NO ,DISPENSER CONTAINMENT YES NO .3 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A:€gU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A r,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 I., 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100°/6 METHANOL COMPATIBLE W/FRP PROTECTION A`.0«9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHAMCAL LINE LEAK2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING ❑ MONITORING © LEAK DETECTOR [:] SHUttbWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORING TEA ❑ 6 TETANK STING ❑ 7 MONITORCONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK E] 95 UNKNOWN Yr 99,OTHER R VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) v ,; 1.ESTIMATED DATE LAST USED(M AYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [j No ionisMSUBSTANCE REMAINING 3100 GALLONS - INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PURY TO THE EST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME y m 7L DATE (PRINTEDfi SIGNATURE) -Keith A. 1.�.11ia'"`ta.ge 6 4/c ?, '^ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF,TW FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I ;# m � 6 g I 5!� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXP THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPL D FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFAMERGROUND STORAGE TANK REGULATIONS FORM B (6.95) r � 1