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STATE OF CALIFORNIA o~� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM B COMPLETE A SEPARATE FORME FOR EACH TANK SYSTEM. MARK ONLY ;1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SIT ITEM{ 2 INTERIM PERMIT F-1 a AMENDED PERMIT ❑ fi TEMPORARY TANK CLOSURE � B TANK REMOVED UME DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNER'S TANK I.D.i 5 157-5`� B. MANUFACTURED BY: C.DATE INSTALLED(MGVDAYNEAR) D,TANK CAP=TY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE TTEM C. ❑ 6 AVIATION GA is REGULAR uNLEADED 3 DIESEL A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL & C. ❑ 1b PREMUM UNLEADED �1 4 GASAHOL O 7 METHANOL ❑ 2 PETROLEUM ❑ B�51J EMPTY ❑ PRODUCT ❑ 1c UIIDGRAD€UN-FOES 5 JETFUEL ❑ 8 MM WASTE 99 0111€R(DESCRIBE IN n A EL MDM ❑ 3 CHEMICAL PRODUCT NKNOWN ❑ ❑ 2 LEADED I Q IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED !v Ill TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND AND ALL THAT APPLIES IN BOX D AND E ❑I 1 DOUBLE WALL ❑ 3 SINGLE WALL WIT EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 Lwxm R TYPE OF ❑ 4 SINGLE WALL IN r VAULT ❑ 99 OTHER SYSTEM 2 SINGLE WALL 1 BARE STE0. ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLAS B. TANK UITERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLC'- ]E ❑ 7 ALUMINUM ❑ B to0S6 METHANOL COMPATIBLE WfFRP (1pI11�ryTenk) 9 BRONZE 10 GALVANIZED S 95 UNKNOWN ® 99 OTHER t RUBBER UNEO ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHQVOL]C LINING �,lli RIOR (�,�--UNUNEO ❑ 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS UNING iC� IIA7ING IS LINING MATERIAL COMPATIBLE WITH 100x METHANOL' YES NO— D.ECTERIOREl1 POLYETHYLENE WRAP F72 COATING ❑ 3 VINYL WRAP ED4 FIBERGLASS REINFORCED PLASTIC WRROSION 91 NONE El UNKNOWN 17199 OTHER _ PROTECTION F75 CATHODICPROTECTION �` SPILLCONTAINMENT INSTALLED(YEAR) Is, OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR} 1<SPILL AND OVERFILL,etC DROP TUBE YES NO ST;; PLATE YES NO DISPENSER CONTAINMENT YES NO N.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF :DERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AG 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B.CONSTRUCTION A 1 SINGLE. WAD_ A U 2 DOUBLE WAL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER YATERIALAND A 1 BARE STEEL A U 2 STAINLESS S ,EL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE 6 CONCRETE U 7 STEEL W/COATING A U B 700% METHANOL COMPATIBLE WI CORROSION A U 5 ALUMINUM A U PROTECTION A U 9 GALVANIZED STEEL. A U 10 CATHCOIC P OTECTION A U 95 UNKNOWN A U 99 OTHER D.BEAK DETECTION 1 OhECK&MEI Pubw G1 LINE LEAK ❑2 ❑TESTM 3 31 vr>ERsr ruL tom+ OEIEC1dP ❑5 sHtrtooverl ❑,99 OTHER�1 V.UINK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION INVENTORY ❑{ 3 i•3N ORING ❑ d GAUG AUTOMATIC TANK ❑ 5 GRCUNO WATER MONITORING ❑ 6 ANNUAL TESTING 7 CONTINUOUS ON IND NG INTERSTITIAL ❑ 8 SIR I _l g --N GAUGAING ❑1p TESTING TANK UNKNOWN ❑ 99 OTHER VLTANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE; 1.STIMATEO DATE LAST USED(MO/DAY Y7�� 4 a WAS TANK FILLED WITH ❑ NO �/// ( 2 ESTIMATED REEMv,'1NNIING GALLONS INERT MATERIAL 7 � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEF.JURY,ALIO TO 7HE BEST OF MY KNOWLEDGE, IS TRUE:AND CORRE DATE FTANK OWNERS NAME n 'E.L]8 S�GNATUREI /I f {t I /!_ 7- LOCAL AGENCY USE ONLY THE STATE J.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION;1 FACILITY# TANK R STATE 01m PEWIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ED THIS1x7RM MUSTSHOULD BE ACCOMPANIED BY A PLOT PLAN, FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ll DERGR UND STORAGE R TANK REGULATIONS T3 FOP"B (6.95)