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From: LARRY SHEPHERD To: STEVE SASSON Date: 7/19/99 Time: 4:22:08 PM Page 2 of 3 I STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FOR 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I (. BARK ONLY 71 1 NEW mnmrT ❑ 3 HkNEWAL PERMIT a S CHANCE OF INFORMATKW O T PERMANENTLY (:I OSFf) ON SM ONE am ❑ 2 WrERDA PERAYT ❑ 4 AMENDED PERM lTr ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ORA OR FACILfTYNAINEWHERETANKISINSTALLED 1 L'aC�' Gc�- 1 i- Go J�/Gz� ��'v�� 1i<� I. TANK DESCRIPTION OOMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OYREPrS TANK L D. i �,( � + B. MANUFACTURED BY' C. DATE INSTALLED (MOI)AY/YEAR) D. TANK CAPACITY IN GALLONS: 0 W. II_ TANK CONTENTS IF A-1 19 MARKED. CCMAPLETE REM C. A Er 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. L- 1A ROULAR UTAM60 3 OIGSEL 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPIY ❑ 1 PRODUCT 1b PREMIUM UNLFADW 1c M03WE UNLEADED 4 GASA40L ❑ 7 METHANOL 8 JET FUEL ❑ 8 MBS ❑ 3 CIEMICALPRC("T ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCM9iNrTEMQ8i10W) D. IF JA, 11 IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A S. 0: III_ TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. S. AND C, AND ALL THAT APPLIES IN BOX D AND E IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE JCJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH E)rrER10R UNER ❑ S INTERNAL BLADDER SYSTEM ❑ 96 UNKNOWN A. TYRE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL W A VAULT ❑ D9 OTHER 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL Q 3 FIBERGLASS ❑ 4 STEEL CLAD W! FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ S CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP {PTIft" 1000 ❑ 9 BRONZE a 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING UNNN3 OR 0 5 GLASS LIN9413 ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING tS LN1NG MATERIAL COMPATIBLE WITH 100% METHANOL P YES — NO— DETECTM D. E)ITEMOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El CATHODIC PROTECTION F191 NOISE ❑ 9s UNKNOWN ❑ 99 OTHER �I. SPALL AND OVERFILL. BIC SPILLOONTAWAENT IN(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YN:AR) DRO!• TUBE YE9 h10 5f A1KER PLATE YES NO DISPENSER CONTANMGNT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE k1g, SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A49 2 DOUBLE WALL A U 3 UNED 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U S 100% METHANOL, COMPATTBLEWMAP PROTECTION -SL- A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D LEAK DETECTION ❑ 114`'"'T"L UR IiAK E]2 tare Wfia OMWVDA FMiVWMAL 4 13Loorn LME a AIA WTIC PUMP �,� SFRAWM DETECTM TisTIKN M DWOF" UAK DETECTOR TANK LEAK DETECTION 7) 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK ❑ 5 GROUND WATER a 6 ANNUALTANk REDONCpJ 7W MONITORING GAUGING MONITORING TEST1t4G 7 �NCON17� S t1TERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL E]10 MONTHLY TANK ❑ 95 UNKNOWN ❑ B9 OTHER VI. TANK CLOSURE INFORMATION (PEfMAANENT CLOSURE W"nACE) 1, ESTIMATED DATE LAST USED (MOIDAY/YR) 2. ESTIMATED OUANTTTY OF 3. WAS TANK FILLED MRTH YES PAD ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 9 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT TANK OWNERS NAME (PRrRiDi BF°""—n <,, -)/VJs C�•..a �. /lf`AI Al-'=lJP i I ICG ANI V Twv cTATF I n MI IMR1-A IS fYOPOSFD tlF THE FOUR NUMBERS 8ELOW COUNTY 8 Jl1RIStACTION 4 FACILITY II' TANK k 00 STATE I.D.# LJ—L I F I I -L= 01-51ABM PERMIT NUMIER PERMITAPPROYED BYIDATE PERMIT EXPIRATION DATE I� TH6 PDFM MUST BE ACCWAM1ED BY A "JIMIFT APPLICAMN • FORMA, UNLM A CURRENT FORM A HAS BEEN FILED. FOR14 C nusr BE GUw L&TEU FEAR Ors TIOLA Nuns. Imo rvrr SHOULD BE ACCOWANED BY A PLOT PLAN FILE THIS FORM WITH THE LOCAL AGENCY BILEYENTIM THE UNDERGROUND STORAGE TANK REQVLATIONS FORM 8 (6485)