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From: LARRY SHEPHERD To: STEVE SASSON Date: 7119199 Time: 4:22:08 PM Page 3 of 3 STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD V m� UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B CII •M� . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARL( ONLY 1 NEW PERMIT ❑ 7 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7' PERMANENTLY CLOSED ON SIT ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL RENIS - SPECIFY IF UNKNOWN A OWNER'S TANK 1. D. 4 l --. !) �/T i7 l B. MANUFACTURED BY: � -07 v C. DATE INSTALLED(MOIDAWYEARI J7 D. TANK CAPACITY IN GALLONS: 6wll- 65 ❑ 94 OTHER 11 ❑ 95 UNMOWN ❑ 3 CHCAL PRODUCT KN �-''J 7 l 2 WASTE II, TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A E.! 1 MOTOR VEHKX.B FUEL ❑ 4 OIL B. C 1s REO" UNIE ED3 ❑ 5 INTE14 NAL BLADDER SYSTEM ❑ 95 UNI0IOWN IMP59L 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BD EMPTY ❑ 1 PRODUCTEMI ❑ lb PREMNAI UNLEADED Ed tC YIDED GWI UNLEAD ❑ 94 OTHER 4 GASAHOL ❑ 7 METHANOL 5 JET FUEL 8 M85 ❑ 95 UNMOWN ❑ 3 CHCAL PRODUCT KN �-''J 7 l 2 WASTE ❑ 2 LEADED ❑ 4 STEEL CLAD W! FIBERGLASS REINFORCED PLASTIC 99 OTHS (DE.S RIBE IN REM a 62ZM D. IF (IL1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A S. 0; III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX 0 AND E A, TYPE OF z I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTE14 NAL BLADDER SYSTEM ❑ 95 UNI0IOWN SYSTEM ❑ 2 SINGE WALL ❑ 4 SINGLE WALL IN A VAULT A4P2 DOUBLE WALL A U ❑ 94 OTHER B. TANK ❑ 1 BARE STEEL U 2 STAINLESS STEEL JZ 3 FIBERGLASS ❑ 4 STEEL CLAD W! FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1D0% METHANOL COMPATIBLE WIFRP P*-yT*ok ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTI RIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING UNMIOOR ,� 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINM MATERIAL COMPATIBLE WITH 100% METHANOL? YES — NO— D' EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL VASAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PRDTECTIDN E:]97 NONE ❑ 95 UNKNOWN❑ 99 OTHER VENTkON OUIPMENT INSTALLED (YE CONTAINMENT INSTALLED (YEAR} OVERFILL PREEJIRI E. SPILL AND OVERFILL, Ott DROP OROPTUBE YES NO STRIKER PLATE YES. ___ __ NO DISPENSER CONTAINMENT YESNO IIP. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTM M A 6> 3UCTM A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER EL CONSTRUCTION A U 1 BINGLE WALL A4P2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERUIL AND CORROSION PROTECTION A U 1 SAKE STEEL A U 5 ALUMINUM A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U L A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A41 4 FIBEAOLAS6 PIPE 7 STEEL W100ATING A U 8 1007E METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Ln LM F7 1 C:]2 UIE 6I 3 IMfSIGTRYL ❑ N i7 ❑ 5 AWMTX RW ❑ � Y. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL iNvFuToFry RECONCILIATION ❑ 3 vADozE MONITORING ❑ 4 AUTOMAT1GAUGING C TANK ❑ 5 M GROUNDWATER ER ❑ 6 ANNUAL ING 7 MONO IR NO INTERSTITIAL ❑ 6 SIR ❑ 9 TAH LYAUGING ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN•PLAC£j 1. ESTIMATED GATE LAST USED (MCWAYIfR) 2 ESTIMATED QUANTITY OF { 3. WAS TANK FILLED WITH YES [:]NO ❑ SUBSTANCE REMAINING GALLONS i INERT MATERIAL P THIS FORM W BEEN COMPLETED UNDER PENAL TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, lS TRUE AND CORRECT TAMS OWNER'S NAME�DDAATE d /� ("%-=ASxYM11m � �TJIX/0,19 /y LOCAL AGENCY USE ONLY THE STATE LD_ NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY! JURISDICTION M FACILITY 0 TANK• CC)—/ STATE I.D;#m ❑� FFF 0 I 5 a HERMIT NUMBER PERMIT APPROVED BYPOATE PERMIT EXPIRATION DATE 7 9y THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A. UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST 8E COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPAIMED 8Y A PLOT PLAN. RLE TMS FORM WITH THE LOCAL AGENCY IMPLONJTTCM3 THE UNDERGROUND STORAGE TANK REGULATION & FORM 6 (6.05