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L.Y i STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rOMPI ETF A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1' 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PER ENTLY CLO ON TE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B K RE OVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. INI1 f\ VLJV1111 IIV1. �v.i�..�...._••-...- _. ___. _ C. I-__-1 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS B. MANUFACTURED BY: L ? - J A OWNER'S TANK I. D. A /. li C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: w VEHICLE FUEL ❑ 4 OIL B. C. I-__-1 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR rx /, t 1b PREMIUM UNLEADED O 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY lyl PRODUCT ❑ 1c MIDGRADE UNLEADED a 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED U 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. N: ... ..... .....1..�.�1 l- nu ... -._ _....... - 11.,..11 A P AAIn r AMn Al I THAT APPI IFS IN ROX D AND E .-. _._._. _ ...��...... �..�.. _ _ _ _ _._ - - ...._ ..- 11 .r in P.T4 IC ADPI IrARI F Iv. r1rwiu 1111 WFIMM 11v1. ...,..�� + „•�.•-.�.. -_.._ _.. _ - I 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. CONSTRUCTION 1 BARE STEEL [:]2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.It4TERIOR LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES — NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 ❑ s CATHODIC PROTECTION ❑ NONE ❑ 95 UNKNOWN 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL P,PEVENTION EQUIPMENT INSTALLED (NEAR) DISPENSER CONTAINMENT YES NO E. SPILL AND OVERFILL, etc. DROP TUBE YES NO STRIKER PLATE YES NO .-. _._._. _ ...��...... �..�.. _ _ _ _ _._ - - ...._ ..- 11 .r in P.T4 IC ADPI IrARI F Iv. r1rwiu 1111 WFIMM 11v1. ...,..�� + „•�.•-.�.. -_.._ _.. _ - A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A O 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 6 100% METHANOL C� MPATIBLE W/FRP CORROSION PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER. t t%- ECHAMCAL LNE LEAK2 ❑ LINE TIGHTNESS CONTINUWS INTERSTITIAL [:] 4 ELECTRONIC UNE AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION DETECTOR TESTING MOMTOWNG LEAK DETECTOR SHUTDOWN 111 1 1 v ncTCnTI AAI '. IANIN LCAN VCICli11Vf1 ��❑ 11 VISUAL CHECK ❑ 2 MANUAL I INVENTORY ❑ 3 VAD02-E ET"IATION 4 GAUGING IC TANK ❑ 5 MONITORING GROUNDWATER ❑ 6 TESTINGRECONCTANK `� ' 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WANK LY MANUAL ❑ 10 MO TES�NGY TANK ❑ g5 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E:] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 TNI r+ AAnt ccn AI T - I InF(7 A PrrWAI TY F PFR./URY. AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT r-vnrvi rVio TANK OWNER'S NAME (PRINTED A SIGNATURE) DATE n ID ^nunncr:n n[ TUC Vn"l7 NUMBERS BELOW LUGAL AGENCY UJt UNLT THE STA It LU. 11Umor_n w 1-11 v�� COUNTY k JURISDICTION a FACILITY B 06).3/1p TANK N O15 STATE I.D.# m ❑❑ o o S PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Tulc Cnau MA, UNLESS A CURRENT FORMA THIS FORM MUSTSHOULD BE ACCOMPANIED BY AIPLOT PILAN. FILE CATION FTHIS ORM WITH THE LOCAL AGENCY (IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL'A,�TIIOONN,(/S{(, FORM B (6-95) "'J " � UJ