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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. a -- MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: SU eAe C4ga E/C -*loq /72 /-RitinD RPG iathrD C0.. I TAMK nFsr.RIPTInN MUM FTP All ITEMS- SPECIFY IF UNKNOWN ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE A OWNER'S TANK I. D. # / (! - S B. MANUFACTURED BY: E2N LOV /-fY C. DATE INSTALLED(MOIDAY/YEAIR) D 6-l5- $' D. TANK CAPACITY IN GALLONS: �O DD ❑ 2 WASTE It TAMK P.nuTFNTs IF AA IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C. ❑ 18 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ED1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT iC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A S. #: 111 TAKIV PnMQT0I If TInM umV nMC I�KA nui v IM ROYFR A R ANn C. ANO ALLTHATAPPLIES IN BOX D AND E ITT OIDMG IMFnou ATInN PIo,C A IF ARnVF rPnI Nn OR U IF UNDERGROUND. BOTH IF APPLICABLE A. ® 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. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 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 C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _4/_ NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC SPILL CO MAI NMENTI�JSTALLED(YEAR) OVERRLLPREVENDON EQUIPMENT INSTALLED (YEAR) ✓ V NO E. SPILL AND OVERFILL, etc. DROP TUBEYES_J! NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENTYES ITT OIDMG IMFnou ATInN PIo,C A IF ARnVF rPnI Nn OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 A@ 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A UO 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER - D. D. LEAK DETECTION ® MEGINOGL uxE IFA¢ oErEcrCa ❑� 2 uxE rNxlrass 3 LONTIMIWS N WW. 4 FIECIRWIC UNE ® uaaronNG ❑ [EAI( DEIELTOR 5 AW%tAnC P9MP 99 orHDT sNulCovm ❑ V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORY ❑ 3 MONITORING ®4 GAUGING AUTOMATIC TANK E]5 GROUND MONITORING TESTING F-78 TTEESTINGTANK ® 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUT AL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITORING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED OUANTTTY OF 3. WAS TANK FILLED WITH YES ❑ NO❑ SUBSTAGE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME /f • ,. - ,%� Q� DA/TAE (�WrE0 61GN�IREj I - �f, {/( /p A/ /1. /T ntC_y%" IlS l l d LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # 47 0705! TANK # 002- STATE O2STATE I.D.# m l51015 $ lP 5 0 I 5 I 8 (o PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE MUST BE COMPLETED FOR THIS FORK MUSTSHOULDCOULD BE AC//O��MPAnNIIED BYY,,,A PLOT PWFKEFORMA, UNLESS A THIS FORM WITH THE CURRENT OCAL AGENCY IMPLEMENTING THqWNS. THIS Fr RGROUND STORE E TANK REGULATIONS FORM (6-95)