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SEP OT '9S 14:12 FROM:I C E S T-619 P 05/06 F-248 RATE OF CALIFORNIA , STATE WATER RESOURCES CONTROL BOARD .�� UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ ] RENEWAL PERMIT ❑ 5 CHANGE OF INFOPMATION ❑ T PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETEALLITEMS - SPECIFYIFUNKNOWN A. OWNER'S TANK L 0.2 B MANUPAOTURED BY: N M k m p w h C. DATE INSTALLED(MUOAYMEAR) 10150Rs D. TANK CAPACITY IN GALLONS: 650 ILTANKCONTENTS IFb116MARKED.COMPLETEITEMC. A 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. t-tR DEG ` GASDIE140L I 6 AVIATION GAS 2 PETROLEUM ❑ Be EMPTY 1 PRODUCT ❑ Ib PREMIU'INLEAPEO 5 11T FUEL ❑ T METHANOL ❑ ] CHEMICAL PRODUCT ❑ % UNKNOWN ❑_2 WASTE - `❑ 2 LEADED N OTHER (DE6CRIBE IN ITEM 0. BELOW) 0. IF(A.1)Il NOT MARKED. EMEA NAME OF SUBSTANCE BTOREG 0.A B.A IH. TANK CONSI _IT—RIUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANO C,ANO ALL THATAPPUES IN Box I. A. TYPE OF 1 DOUBLE WALL ❑'I ] SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 BINOLE WALL -,I • SECONDARY OONTAINMENT (V,"TEO TAmq ❑ „ OTHER _ ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS £TEFL F72 FRERGLASS ❑ K STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL U 5 CONCRETE ❑ B POLYVINYL CHLDPIDE 7 ALUMINUM ❑ B 100¢ METHANOL COMPAYIBLE W/FRP (Pdm2ry TAnkl ❑ 9 BRONZE 10 GALVANIZED STEEL C, 96 UNKNOWN U 0 OTHER _— _— ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ] EPDXY LINING ❑ A PHENOLIC LINING - - - 0.INTERIOR ❑ 5 CLASS LINING ❑ 6 UNLWED % UNKNOWN ❑ 99 OTHER UNWG —" IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL T YES— NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING S VINYL WRAP K FIBEROLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION n Bl NONE 96 UNKNOWN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEOROUNOOR U IFUNDEROROUND.BOTMRAPPLICABLE A. SYSTEM TYPE A U I BUCTION A U 2 PRESSURE A U 2 GRAVITY A U BB OTHER _. B. CONSTRUCTION A U 1 BWOLf WALL A Y S OOUBLG WALL A M P LINGO TPENCM A(pK VNKMOWH •-Uft mNEn C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U ] POLYVINYL CHLORIDE IPVC)A U A FIBERGLASS PIPE CORROSION A U 0 ALUMINUM A U a CONCRETE A U T STEBLWr COATING A U S 100. METHANOL COMPATIBLE WIFRP PROTECTION A U 9 CALVANIZEO STEEL A U 10 CATHODICPROTECTION A©06 UNKNOWN A U 09 OTHER D. LEAK DETECTION ❑ I AUTONATICLINEL£AKO£TECTOR ❑ 2 LINE TICMTNESBTESTING ❑ '�B�oRIRe�❑00 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 2 VAPOR MONITORING F1 K AUTOMATIC TANK GALIWNG❑ 6 GROUND WATER MONITORING S TANK TESTING T wTEniTITP1L MONITOM1ING 0 01 NONE C�] E, UNUNO" O 9H OTHER VI,TANK CLOSURE INFORMATION 1,ESTWATED DATE LAST USED(MOIDAVIYR) 7Eu—Tams EOOUANTrtY OF 0.WAS TANK FILLED WITH YES U NOn SUBSTANCE REMAINING GALLONS INERTMATERAL t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT RT'S DATEAPPELCAYWW4ccYng 1-1_q LOCAL AGENCY USE ONLY THE STATE LD.NUMBER 15 COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION FACILITY# TANK► STATE I.Dl 7n ( 7] El 1 I I_] 1-71 1 11 1 1 _ VCi1MiTNUM8ER PERM IT APPROVED BYIOATE PERMIT EXPIAATION DATE FORM a(B-SOI THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM"