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STATE OF CALIFORNIA (4: STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Boe d; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. B. �/• vl PRODUCT ❑ 2 WASTE O ❑ry /1aR REGULAR LYJ 'PREMIUM UNLEADED ❑ 2 LEADED MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC 1. IANI%uratttIY11UN COMPLETE ALL ITEMS- SPECIFY IF I INKNJwm A. OWNER'S TANK I. D. # B. MANUFACTURED BY: ,N 0 I" /&r/) rJ V C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLLONS:^�Z IL IANK UUN I EN IS IFA -1 IS MARKED, COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL ❑ 2 PETROLEUM ❑ 80 EMPTY 3 CHEMICAL PRODUCT ❑ ❑ 85 UNKNOWN B. �/• vl PRODUCT ❑ 2 WASTE O ❑ry /1aR REGULAR LYJ 'PREMIUM UNLEADED ❑ 2 LEADED ❑ ❑ ❑ ❑ 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ 7 METHANOL 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # III. IAINM UUINN I NlICt1[]N IY. rIrmu IINruiruv A11u1N CIRCIF eIFeRhVFnoni ininno 11 is imnoe..e..... ....�..._......._-_._ A. SYSTEM TYPE _ _.._._....__..__...-.....--.-I--11. - -IF .",.vn �n'uc A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER D 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR5 ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)AgnR OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IY. rIrmu IINruiruv A11u1N CIRCIF eIFeRhVFnoni ininno 11 is imnoe..e..... ....�..._......._-_._ A. SYSTEM TYPE A UF SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE p U 10 CATHODIC PROTECTIO 3 POLYVINYL CHLORIDE (PVC)A U 7 STEEL W/ COATING A U A U 95 UNKNOW A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE WIFRP 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONITORING ❑ 99 OTHER I. TANK LEAK DETECTION ❑ 1 VISUAL CHECK E,2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORINC ❑ 6 TANK TESTING Yr7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. 1 ANK CLUSURE INFORMATION 1. ESTIMATED DATE LAST USED IMO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF?IRVURY, AND TO TIJE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS M / (PRINT EDB SIGN Inll�� .� DAT / 1 -^ LwAL MUCIV , T UOM UNLT _ I HE S TATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDA COUNTY # JURISDICTION# FACILITY# TANK# PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE i FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 dt q FOR0071&RS