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A"9- 31 -99 11 : 03A He lwk S. Lerrl4--�r Inc . . P . 03 STATE OF CAUFORKA - STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 4 1 rIb•N► COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. K ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 75 CHANGE OF WrCRMATION 7 PERMANENTLY CLOSPD 0H SITE MARKAR ONL ❑ 2 INTERIM PERMIT © i AIJENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 9 TANK REMOVED ' TEM 011A DA FACILITY NAME WKERE TANK 13 INSTALLED- 1. TANK DESCRIPTION COMPLETE ALL A(Eu3- SPECIFY IF:UNKNOWN ' A. OWNER'S TANK I.O.0 S. MANUFACTURED SY: C. DATE INSTALLED(Alp'OAWYEAR) D. TANK CAPACITY IN GALi.ONS: ILTANK CONTENTS LF A-1 IS MARKED.COMPLETE ITWM C. MOTOR VEHICLE FUEL p 4 CML S. C. 1r REGULAR L LLFu3EO 3 DIESEL S AVIATION C;A$ lb tiREWUN UNLEADED L QASAHOL 7 McTHANOL 2 PETROLEUM ED EMPif I PRODUCT Sa MiL'G)iArJE UNLEPDED 6 JET FUEL 8 MIS3 CHEMICJNLPRODuCr CD96 U14KNOWN �2 WASTE 2 LEADED � GF OTHERIDERGAIBEWREL10,6ELOr+) ' D. LF i)ISNCT MAAYEQ, ENTER NAME OF SUMANCrk VORED C.A.S.i III. TANK (CONSTRUCTION AAARK ONE ITEM ONLY 1N Bc xrs A.B.AND C,AND ALL THAT APPLIES IN BO:D AND E ' A. TYPE OF m I DOUBLE WALL ❑ 3 SINULG WALL WITH EXTERIOR UNER 5 WTFRNAL READS 3YS7r.M ❑ 06 UWM:IWN SYMM 71 2 SIM3LF- WALL ❑ A SINGLE WALL IN A VAULT 90 OTHER 0. TANK X I SARESTEEL ❑ 2 9TAINLESS STEEL ❑ 3 FIBERfl1.4S9 4 STEEL CLAD W1PI6FR(jLAR3REtNFORCEDPLA ST[C MATERIAL ❑ 6 CONCRETE ❑ 6 POLYVINYL CHUIFIIDE ❑ 7 ALLIMINUTA ❑ 9 Ioa-A MESIiANOL COMPATSDLE W/FRP (PdnmrITo* 0 BRONZE 10 GALVAMZT:O STEEL ❑ 9a UNKNOWN 99 OTHER C.INTERIOR f7 1 RUBBER LINED 2 ALKYD UMNa 3 EPDXY LINING ❑ 4 PHENOUG UNINo ' LiNINQ OR ❑ 6 GLASS LINING 6 UNLINED C:� 06 UNKNOWN O 99 OTHER OaA'Tw0 18 LINING WATER[AL COMPATIBLE WITH tops METHANOL 1 YES_ NO ' D.EXTERIOR ❑ 4 POLYETHYLENE WRAP L] 2 COATING ❑ 3 VINYL vOluo r FIBERGLA66 REINFORCER PLASTIC CORROSION 01 MONS L)95 UNKNOWN ❑ 910 OTHER PAOT'ECTTf1N ❑ As CATHOOIc PROTECTION ❑ SPILL CO AINMENT GTALLED(YEAR} OVERL PFIEVENTI N EOUSPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL /IL. DROP TURF YEB NO IKEA PLATE YES NO DI3PE HC? IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNDED U IF UNDERGROUNf],BOTH IF APPLICABLE A. SYSTEM TYPE A II 1 SUCTION A U 2 PR06LIAE A U 3 GRAVITY A U ♦ FLEX[9LE PIPING A U 99 OTHER 8. CONSTRUCTION A U I SINGLE WALL A DOUBLE WALL A U 3 LBNEO TRENC., A U VS UNKNOtiVN A U W OT}1ER ' C MATMIALAND A U 1 BAPS STEEL A V 2 STAINLESS 97EEL A V 3 POLYVINYL CHLORIDE(PVC)A V 4 F18£RGLASS PIPE CORROSION A U 15 ALUTANUTA A U 6 CONCI TE A U 7 STEEL W COATING A U e Im% METH L Cl, TIBLE WFRP PROTECTION A U t3 GALVANIZ;Cj1 STEEL A U 10 CAT)CWCPROTECTION ■ U is UNKNOWN A OTHER t 5 I[ols�Acu W Lm tm.0,I"s a w.0Jil'MIu-m �"}4 F.fCtAt -[e�Y� �5 IJV OT IR f^I 99 D. LEAK DETECTION [] ❑ T[tIND fibNtafi+9 a REIML V. TANK LEAK DETECTION ❑ I VISUAL CHECK 2 MANUAL INVENTORY A MQNTORINO s ATUO�d 4GTIC TANK 6 GROUND wATER LION TORING ❑ 8 ANNUTESTINGT K ' 7 CONTINUOUS NTPA97MALQ & SIR ❑ a WEEKLY MANUAL ❑10 MONTHLY TANK a 11 UNKNOWN � 09 OTHER MONITORING VI.TANK CLOSURE INFORMATION 4pt%mANE T cLOsun IN-PUCE} t.£6TIMAT60:DATE LA ZT USED IWOCAY1YRI 72.@STIWATEOOUANTITY OF 3.wAs TANK FILL20 WATH YES ❑ NO ' SUESTAI�REEWAININO GALLONS INSRTMATERIAL? ELI 7HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEPJURY,AND 7O THE SE570F MY KNOWLEDGE, 15 7RUF AND CORRECT TAN( OWHEFtS NAME DATE ' IPKKTIID A U6NATU;iJP ' LOCAL AGENCY USE ONLY THE STATE 1,D,NUMeER IS COMPOSED OF THE FOUR NUIBEA8 BELOW COUNTY 4 JURISDICTION 4 FACILITY! TANK 4 ' STATE I.D:# PEI4LJIT NUMBER PEFtlrAIT APPROVED WYMATEE PERMIT EXPIRATION DATE TXW FORM MUST 9E ACrOMPANED BY A RENT TAON•Fom A UNLESS a CURRENT FDPJA A Kka BEE71 FILEVAEkIM C MUST 9E CO WPLETFD Foci IlAITALL1TlON3 THIS FORM SHOULD BF ACCOMPANIED QT A Fuir. FILE THIS Fl RM*TTH THE LOCAL A©NCY IMPLEMEKTIMG 1w VEROAOUNO STORAAE TANK REAULATP)a