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6, Ll STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 4A� MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED OBAOR FACILITY NAME WHERE TANK IS INSTALLED: SU ft C4Fa F /7 _'/Dq 02 LzLtAr gf Ia14rA14 GL- I Tl1\IV MCOPOIDTlnM ,cTv .,, sue_ RORPoNICIINI(NnWN ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE A OWNER'S TANK I.D.# /O Y r B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAYIYEAR) D 6 -1 S-4 8 //(( D. TANK CAPACITY IN GALLONS: 121000 11 TAKIV PF)MTCMTC .. n, w..novrn rn,.., rtcun A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 18 REGULAR UNLEADED 0 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BD EMPTY ® 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM O. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: 111 TANK CONSTRIICTION MARK nNF ITEM ONLY IN BOXES A S. AND C. AND ALL THAT APPLIES IN BOX D AND I17 DIDINY: INC(1RA#ATK1N piaci= A IC ARnvP nROIINO OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE © 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 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 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 ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING ❑X 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES ✓ NO— D• EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ PROTECTION g1 NONE El❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT I TALLED (YEAR) OVERFILL PjiEVENTION EQUIPMENT INSLALLED (YEAR) DROP TUBE YES NO_ STRIKER PLATE YES ✓_ NO_ DISPENSER CONTAINMENT VES NO I17 DIDINY: INC(1RA#ATK1N piaci= A IC ARnvP nROIINO OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACU) 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 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 U A U A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A UO 9 100°6 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION EMI NECHANIGI ONE (FAX �mm 2 UNE IX#nIa35 3 WNINU0115 NR.f611ML 4 RFCmONX: LINE ❑ TEnNG ® MOMrGRNo ❑ (FAX oErEcroR 5 Am01MTIC PUNY gg OTHER slumowX ❑ V. TANK LEAK DETECTION ❑II 1 VISUAL CHECK ❑ 2 RECNUAL O CILIATIONORV ❑ 3 MONITORING 4 GAUGIAuToZE LF] C TANK E::]5 MONITORING GROUND TER F-16 TESTING ANNUAL TANK ✓J 7 MONITORING G INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGING ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MOIDAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME /^' ///'J� //�1 ,y�1, DATE I� r.l (PRINTED AGIGNARIPO / I . I- I Y 1C— - _ O 'A %�//Y... -// /'tom I •Y X LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # D070 9 TANK # oo 4 STATE I.D.# m O 1519 1 (v 15-101 8' 7 1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP"ON- FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED C MUST BE COMPLETED FOR INSTALLATIONS. THIS F' SHOULD BE ACCOMPANIED BY A PLOT RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING ERGROUND STORAGE TANK REGULATIONS /p� FORM (&95) �J�/ {/' �j (� �L I,{J -51aOM8I