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pL60UM p STATE OF CALIFORNIA �p STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B m� COMPLETE A SEPARATE FORM FOR PCH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT '❑ 3 RENEWAL PERMIT Ly5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED NSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 -7 o p� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I. D.s -)-- I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) /A/19 12 D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA -11S MARKED. COMPJ.1<TE ITEM C. A ❑ / MOTOR VEHICLE FUEL Lkr4 OIL B. E:]95 UNKNOWN C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY F-11 BARE STEEL EOel PRODUCT❑ F-13 FIBERGLASS 1b PREMIUM 4 GMETHANOLOL ❑ 7 METHANOL ❑ 5 CONCRETE POLYVINYL CHLORIDE X:l F-17 ALUMINUM ❑ g 100% METHANOL COMPATIBLE W/FRP (Primary Tank) UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN CORROSION ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 5- GLASS LINING ❑ 6 UNLI ❑ 95 UNKNOWN C. A. S. s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B. AND C. AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WAL F]3 SINGLE WALL WITH EXTERIOR LINER E:]95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTNK) ❑ 99 OTHER CONSTRUCTION F-11 BARE STEEL STAINLESS STEEL F-13 FIBERGLASS El STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIA ❑ 5 CONCRETE POLYVINYL CHLORIDE X:l F-17 ALUMINUM ❑ g 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g ggONZE GALVANIZED STEEL E]96 UNKNOWN ❑ 99 OTHER CORROSION ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5- GLASS LINING ❑ 6 UNLI ❑ 95 UNKNOWN ❑ 99 OTHER LINING A U 10 CATHODIC PROTECTION A U NKNOWN A U 99 OTHER D. IS LINING MATERIAL COMPATIBLE WITH 100%M NOLO YES_ NO— AUTOMATIC LINE LEAK D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGF-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-]5 CATHODIC PROTECTION F-191 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGRNND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A lk,3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U NLINED 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 PNYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE /COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U NKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 7STITWL 99 OTHER ❑ MONITORING V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC NK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIA MONITORING ❑ 91 NIXNE ❑ 95 UNKNOWN ❑ 99 OTHER 1,N YMpTED DATE LAST USED (MONAV/YR) 2. ESTIMATEDSUBSTANCETY OF REMAININGGALLONS I 3 WAS IINERT WTERIALl 7H YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRIHTE9 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ly %L% L M a S COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# 4161= �� PERMIT NUMBER I PERMIT APPROVED BWDATE I PERMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. FOROMB.M