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STATE OF CALIFORNIA I -�• '; STATE WATER RESOURCES CONTROL BOARD I( I y 104` 3 m� • •-ce e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , H COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ J RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Lo r/`no,6-,;23 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN O I C 71:? 7I B. MANUFACTUflEO BY: A OWNER'S TANK I.D:! J C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 10 II.TANK CONTENTS IF A-T IS MARKED.COMPLETE ITEM C. 8 AVIATION GAS ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNIEADEO 3 DIESEL ❑ A 10 PREMIUM UNLEADED 8 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT Ic MIDCWE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WAS ❑ 21 ❑ 99 OTHER(DESCRIBE IN RENO.BELOW) D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPUES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER E:35 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEMS SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK BARE STEEL f72 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W1 FIBERGIASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F-16 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100;6 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC UNING C.INTERIOR ❑ 6 UNLINED �SS UNKNOWN ❑ 99 OTHER LINING OR ❑ s GLASS UNING , COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANCL7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4' FIBERGLASS REINFORCED PLASTIC CORROSION �/91' NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTIor ` SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,etc. DROP TUBE YES__ NOS STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUC A U 2 PRESSURE A U 3 GRAVITY A U a FLEXIBLE PIPING. A U. 99 OTHER S. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 B R A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE WIFflP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I MEclwacu uxE tr;uc z MNE 1aa WS ❑3 a IHIERSRRAL ❑4 BECRIGNO uxE ❑5 AVfoMATic PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ oETeaoR ❑ MONO ITAa DETECTOR sHuiOoxw V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3.MAON�ITORING ❑ 4 GAUGG AUTOMATIC TANK ❑5 GROUND MON TORINGTER ❑'8 TE$TINGTANK ❑ 1 VISUAL CHECK ❑ gECONCILIATON 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN . OTHER ❑ 7 MONITORIONG INTERSTITIAL ❑ B SIR ❑ TANK AUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2 ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH YES ❑ NO i ESTIMATED DATE LAST USF7O(MO/DAWYR) SUBSTANCE REMAINING LS-GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJIURY,AND TO THE BEST OF MY KNOWLEDDGE,11 EIS TRUE AND CORRECT TANK OWNER'S NAME / (PRart1m 6 SIGNATURE) % C CO LOCAL AGENCY USE ONLY( THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW TANK N COUNTY N JURISDICTION 4 FACILITY N STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE T FORM A HAS BEEN FILED. FORM MUST BE THIS FORM MUSH OULBE DBEAC DIED BYADBYPERMIT PLOTPIAN. N-FOR FORM ES THE LOCAL AGENCY IMPLEMENTING THE UNDERCOMPLETED INSTALLATIONS. UNDERGROUND STORAGE TA REGULATIONTHIS FOR