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From: LARRY SHEPHERD To: STEVE SASSON Date: 7119199 Time: 4:22:08 PM Page 2 of 3 STATE OF CALIFORNIA F i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FOR B �iII�D�Mtr COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. BARK ONLY 1 NEW rERN1ri ❑ 7 mENEVIAL PERMIT ❑ 5 CHANGE OF INRs RMATH-W ❑ T PERMANENTLY ClOSFD rw 71TI ONE ITEM ❑ 2 IRERNA PERAYT ❑ 4 AMENOED PEKW ❑ 5 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ORA OR FACILITY NAME WHERE TANK IS INSTALLED: I Y- Ac,! ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 6-a ❑ 5 CONCRETE I. TANK DESCRIPTION OOMPLFTE ALL ITEMS - SPECIFY IF UNKNOWN A 01MlER•S TANK I. D. A / ! � i r I B. MANUFACTURED BY! C. DATE INSTAL -I -M (MOIDAWYEAR) D. TANK CAPACITY IN GALLONS: Q f{p. II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. 1 MOTOR VEINICLE FURL ❑ 4 OIL B. C. 1a RCGULAA Lmm"D 3 pGSEL L-7]6 AVIAT40N GAS ❑ 2 PETROLEUM ID 80 EMPTY F-] I PRODUCT 1b PREMIUM UHLEAOEfl 4 CiA5AF101 E:]7 METHANOL 1c MOaWE UNLEADED ❑ 8 JET FUEL ❑ B MSS LPROK:T ❑ 95 UNKNOWN ❑ 3 CN�MICADI ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBibREMD-BELOW) D. IF IA 11 IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C, A. &v NIL TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 2 1 DOUBLE WNL ❑ 3 SINGLE WALL WITH FXTER10R LINER ❑ 6 INTERNAL BLADDER SYSTEM ❑ 95 UNIRom SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL. ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLEwrinp ?T6iT-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER_ ._ _ _. PROTECTION ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR 0 5 GLASS LINING ❑ 6 UNUNEO ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINNG MATERIAL COMPATIBLE MRH 100% METHANOL 1 YES — NO— 11,91 O EIITEISOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROS" PROTECTION ❑ CATHODIC PRbTECTON ❑ 91 NOPE ❑ 95 UNKNOWN ❑ 99 OTHER L) � , SFIILOONTAIIMIEIf INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMF.NT INSTALLED (YEAR) DROP TUBE YES NO STTYKER PLATE YES NO &SPENSER CONTAINMENT YLS NO M PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPUCABLE A. SYSTEM TYPE ALIPI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. DONSTRLCTIDN A U 1 SINGLE WALL AdP2 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) A694 FIBERGLASS RPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL WICOATNO A U S 100% METHANOL COMPATIBLE WIFRP PROTECTION -P &Q.+i7'SRiiL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 9a OTHER D. LEAK DETECTION ❑ 2 UW 1""W°° "E =6 1 "�" `L"i iAl` ❑ -Gals gym'" C] Rw ❑ OTHER TS Ya 11,91 >XM+r V. TANK LEAK DETECTION 7) 1 VISUAL CHECK ❑ 2MANUAL INVE-ENTIORY REC.ONGUATIONN ❑ 9 MONITORING ❑ VADOZE4 GAUGING C TANK ❑ S GMAUTOMATIOATOWNGUND WATER ❑ 6 TESTING,ANNUAL 7 MIDNITORI/O lITERSTITIAL ❑ BSIR ❑ 9 TWEE LY M NU ❑ t0 TESTING MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI, TANK CLOSURE INFORMATION (pawANENT CLOSURE (+-PLACE) 1, ESTIMATED DATE LAST USED WOIDAWlYR) 2. ESTIMATED OUANTTTY OF 3, WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME // a (ORNTf & BIONATUAM �+r I nCAI AGFNJCY "Cr. CIN(V TMG RTik.M Lo MLIMRER L4 OOMPOSFD OF THE FOUR NUMBERS BELOW COUNTY • JtJRISOIC'TION I FACILITY R TANK 9 O� STATE I.D.# ❑ PERMITNUMBER PERMIT APPROVED BYNATE PERMIT EXPIRATION DATE 7 TNM FORM MUST M ACCOMPANIED BY A PEW APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS B EEN BLED. FORM C MAST BE COM UMM FOR RSTAN.ARDIIS. 1= rvMw SMULD BE ACCOaPANED 3Y A PLDT PLJLNL ALE THIS FORM TYtTH THE LOCAL AIW NCY IAPLEMHNTINO TIE UNOERCROLIID STORAGE TANK REI4ULATION6 FORM 9 (64;5)