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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT CI 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ A AMENDED PERMIT a TEMPORARY TANK CLOSURE 5�<] '�, DBAOR FACILITY NAME WHERE TANK IS INSTALLED: % ISI'I1 / I. TANK DESCRIPTION /I COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK D.• ILII / rIJ� S. MANUFACTURED BY: j !�1, rI.Y� / C. DATE INSTALLED A10DAYNEAR) I61-7 j_ I 0. TANK CAPACITY IN GALLONS: 10 000 1 TAAIV CONTPNTB IF 1.1 is MARKED. COMPLEE—i E ITEM C. I MOTOR VEHICLE FUEL ❑ A Oil B. C. ❑ I RESUWL UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A. l_ 7 PRODUCT R1 Ib PREMIUM UNLEADED 4 GASAHOL T METHANOL F72 PETROLEUM ❑ 90 EMPTY 1 0 Ic MIDGRADE UMFADED c:15 3ET FUEL F M85 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED -1B ❑ 99 OTHEROESCRIBE!NREVD.BELOW) 0. IF (AI) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. POLYVINYL CHLORIDE C7 ALUMINUM G A S. a: NK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B. AND C. AND ALL THAT APPLIES IN BOX U ANU e [II. TA r1r11\lR 11\I \/IIYIL IIV I DOUBLE WALL l_ 7 3 SINGLE WALL WITH EXTERICR UNER C:]5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ® 2 SINGLE WALL 1 3 SINGLE WALL IN A VAULT ❑ 99 OTHER B. CONSTRUCTION I BARE STEEL I SINGLE WALL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CUD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE C. POLYVINYL CHLORIDE C7 ALUMINUM B 100: METHANOL COMPATIBLE WIFRP MATERIAL (Primary Tank) i-7� L I 9 BRONZE 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODICPROTECTION 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER LEAK DETECTION I❑ ❑ 1 RUBBER LINED o.(R.y� 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING OR 5 GLASS UNING ❑ 5 UNUNED ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. EXTERIOR Gj 1 POLYETHYLENE WRAP � 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION9L ❑ 5 CATHODIC PROTECTION NCNE ❑ 95 UNKNOWN 99 OTHER PROTECTION $PILL CONTAINMENT INSTAL.LO (YEAR) OVERFlLL PREVENTION C-0UIPMENT INSTAL En (YEAR) SE E SPILL AND OVERFILL, BTG ORCP UYES _ NO _ STRIKER PLATE YES _ NO _ (DISPENSER CONTAINMENT YES_ NO— •AT,I o 11 iC ilullCC]fP1111N11 90T4IFAPPUCABLE I V. r1r11\lR 11\I \/IIYIL IIV A. SYSTEM TYPE A U I SUCTION A 02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A JD I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A(D A U A U I SAFE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODICPROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE T STEEL WICOATING A U a 1007 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION o.(R.y� 2NU ❑3 mYxglti;A ❑a BFCBDIaC L➢F ❑5 ♦IROWiK irRIP 99 OTHP ❑ n r'TATI/1.1 V. INIVn LLNn uCl �u uvn ANNUAL I VISUAL CHECK 7_72 MANUAL RECONCI IATION INVENTORY El VADOZMONITl7RING 4 GAUGING AUTOMATIC TANK 5 MONITORING TANK T� ❑ B TESL NG ❑ T MONTOR UG INTEiSIMAL S SIR ❑ 9 TANK MANUAL ❑ to MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE I. ESTIMATED GATE LAST USED (MOIDAY/YR) I 2. ESTIMATED OUANTTTY OF I 3. WAS TANK R 1 Fn WITH YES C:] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 i HIS FORM HAS 3E5V COMPI QED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT 'ij� LOCO TANK OWNER'S NAM?.� TDATE (PRINTED a MISNATLIRE) U�," Ao{7(1T r 47A r T /t o M7 K\ A) Ar.FNry I I6;: III Y THE STATE LO. NUMBERWCOMFOSED OF THE FOUR NUMBERS BELOW LW Y COUNTY x JURISDICTION A FACILITY S 1/�b� TANK k STATE I.D:nLi I'`)Q 31 I iQ h : / ITER I PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLY "IN - FORM A. UNLESS A CURRENT FORM A HAS BEEN FILED. FO^" ^ MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P V THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE WUND STORAGE TANK REGULATIONS FORM 8 (6-95)