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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD :� 44 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B -eB �° �n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED QNSrre ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4;r Nie! V A0 coj n O 12s I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.A 3 9-S05'oq Cl - 02_ S. MANUFACTURED BY: UYLKn Ow✓\ O' C. DATE INSTALLED(MDAYIYEAR) 19 2 1 (7`J D. TANK CAPACITY IN GALLONS: 55-D II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ t MOTOR VEHICLE FUEL ❑ 4 OIL 8. C, 18 REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS tb PREMIUM UNLEADED s GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM co BO EMPTY 1 PRODUCT Ic MIDGIWE UNLEADED a 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 89 OTHFA(OESCWBE IN ITEM O.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.e III. TANK CONSTRUCTION MARK OE ITEM ONLY IN BOXES A S,AND C,AND ALL THAT APPLIES IN BOX D ANO E A TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ S INTERNA.BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 8 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Armory TOA ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ ♦ PHENOLIC UN1NG LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNO ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL7 YES_ NO7 D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS RENFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ®95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,@IC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES- NO- STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U T 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)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVMIIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION OENFCfoR MIE 2 t1s1190 3 a x ME s A1rtoMATlc PUF Npn<Tfq ❑ LEAK OETEc1aB 9ArtO0WN 99 oTNeR(J71 DWV\ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RREECONCIUATIONNUAL ORY ❑ 3 VADOZEMONITORING e GAUGING AUTOMATIC TANK ❑ 5 MON TORINGROUND �R ANNUALTANK ❑ B TESTING ❑ 7 CCONITOR U INTERSTITIAL ❑ 8 SIR ❑ 9 TIEK LY MA,:UAL [:110 MEOSNTHLY TING TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH ,ES ED No ,-.. ��50 SUBSTANCE REMAINING GALLONS INERT MATERIAL? El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME � DATE IPRPl1mASIGNATUPE) Eq \\4L_S"TOIJ S 3 °l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION♦ FACILITY k 7268 TANK R STATE I.D.# m U I &'I Fryll 1d1';, Wev 0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 0 (A THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUrATION•FORM A UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOO INSTALLA NS.THIS FORM FORM E (6-95) t( BE ACCOMPANIED BY A PLOT THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFR STORAGE t TANK REGULATIONS fi6196Po 44L