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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 1 NEW PERMIT F--1 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED OPLSITI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED �cyj DBAOR FACILITY NAME WHERE TANK IS INSTALLED' SEER�^ .I ✓IEIaAfK ftIt q 192 LG TA IV nCCPCICTInM i iT Ric- z=r.IFY IF UNKNOWN A OWNER'S TANK I D k / p y» VB. MANUFACTURED BY: /'l df 1A C LL4,Y 4 C DATE INSTALLED (MO/DAY/YEAR) ()6-/j ' 9 D. TANK CAPACITY IN GALLONS: 2 U! O UGl J u TAAIV ^MKITC\ITC D COMPLETE ITFMG A O 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, X 19 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ ID PREMIUM UNLEADED . ❑ 4 GASAHOL ❑ T METHANOL F]1 PRODUCT 2 PETROLEUM ❑ 80 EMPTY ® ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOYO D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A S. a: TRUCTION K O NE ITEM ONLY IN BOXES A B AND AND ALL THAT APPLIES IN BOX D AND III. TANK CONS MAR ® 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 3 GRAVITY A U F -]i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary T=k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER KECHNACN WE IFAN )ELECTOR ❑ ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING 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❑ ❑ 5 CATHODIC PROTECTION ❑ Be NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTOVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) AINMENT II STALLED (YEAR) PLATE VES �_ NO DISPENSER CONTAINMENT YES —&f- NO E. SPILL AND OVERFILL, BIC. DROP TUBE YES ✓ NO_ STRIKER __ IV. rlrinu Inrvmmil Ievl\ 111 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 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 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U B CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE T STEEL W/COATING Ao B 100% METHANOL COMPATIBLE WIFRP A U 95 UNKNOWN A U 99 OTHER— D. LEAK DETECTION D. ® KECHNACN WE IFAN )ELECTOR ❑ 2 BNE ilGfIfNE55 ®3 CCMINUWS INIB45iI1LLL ❑ 4 ELECTRONIC UNE 1�I TESTING LNINRd IFAN OEIELT011 CJ 5 AUfOM4TIC PUHP ❑ 99 SER SHuiIXIWx I. IANIL LEAK UCICMTIvI\ F-11 VISUAL CHECK ❑ 2 MEANUCO L AL INVENTORY ❑ 3 VADOZE LNG 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGROUNDWAG TESTING ❑ 6 TESTINGANNUAL MONITO TANK TION 9 WEEKLY 10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER LKTNJNUO GINTERSTTI❑B SIR TESTING MOTANK GAUGING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MOIDAWYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUB STA NCE REMAINING GALLONS INERT MATERIAL? _..... _. _ _ ,._.... •.,., ..,.. 1 ,•ur .CC7 nc AAV IINnWI FnRF. IS TRUE AND CORRECT THI YVHM IYHJ OCcry L.vmrLu L✓ v,...�, • • - - - - --- DATE TANK OWNER'S NAME �A _,/.L /%cj PINim4GGNANRLT ,3f �'f1 Ogg., LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY% JURISDICTION a FACILITY# DO%o5,ef TAI E I = STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT E%PIRATION )ATE THIS FORM MUSTSHOULD BE ACCOMPANIED BY AIPL.OT JW FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THT FORM A HAS BEEN FILED. IVE GROUND STORAGE TANK REGULATONSNS. THIS FOAM FORM B (6-95)