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! IyIB'1 ,DMA Ix 10,13 1Dq STATE OF CALIFORNIA �• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE 1 NEW PERMIT MARK ONLY ❑ ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [__1B TEMPORARY TANNKpCLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LO 1016— o6e, 3a 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# IS 1 V 15 B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAYf(EAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-t IS MARKED,COMPLETE ITEM C. 1a REGULAR UNLEADED 3 DIESEL E] B AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. lb PREMIUM UNLEADED 4 GASAHOL O 7 METHANOL F72 PETROLEUM F-180 EMPTY ❑ 1 PRODUCT is MIDGRADE UNLEADED 5 JET FUEL ❑ 0 M8 ❑ 3 CHEMICALPRODUCT cg�l95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REND BELOW) D. IF(AI)ISNOTMARKED. ENTER NAME OFSUBSTANCE STORED C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E F-1i DOUBLE WALL ❑ 3SINGLE WALL WITH EXTERIOR LINER C:] 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN A.TYPE OF SYSTEM � SINGLE WALL ❑ s SINGLE WALL IN A VAULT E:] 99 OTHER B. TANK � BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOUC LINING C.INTERIOR LINING NG OR ❑ 5 GLASS LINING ❑ e UNLINED (f�5 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION Np /91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC.PROTEc-n SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION E505 07: NET LED(YEAR) E SPILL AND OVERFILL.#LG DROP TUBE YES__ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES 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 4 FLEXIBLE PIPING. A. U. 99 OTHER U 99 TITHER B. CONSTRUCTION A U SINGLE'WALL A U X DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A C. MATERIAL AND A U I BRE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A U B CONCRETE A U 7 STEELW/COATING A U B IDD% METHANOL COMPATIBLEW/FRP CORROSION A U 5 ALUMINUM PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER C 1 MEI:fUNGI UNE LEN( 2�ST�NESS ❑3 EDNIaal0113 wTA3TML ❑4 MECIR 0 1114 ❑5 AVIOMITC PUW ❑ 99 OTTER A&2✓ D. LEAK DETECTION ❑ 06TEc10R ❑ uoxroRwa LAK OErEcroB a1010°"a' V.TANK LEAK DETECTION EEC] VISUAL CHECK ❑ 2 pMANUAL INVENTORY ❑ 3 LIATION VADOM IORING ❑ 4 GAUGIAUTONG C TANK ❑5 MON TORINGGROUND TER ❑ 8 TESTINGANNUALTANK 7 MON TOR NG NUOUS INTERSTfT1AL ❑ 8 SIR ❑ 9'AF K(LA MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN �.� OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2 ESTIMATED OUANTTIY OF (�/y��/ 3.WAS TANK FILLED WITH YES ❑ NO� 1 ESTMATED DATE LA5i-U3 ,(iO/DAY/YR) SUB STANCE REMAININGALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJjJRY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME l / 0 (PRWfED6510NATJRkT /` C /�' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LDA m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUSH BE ACCO P DIED BYAD BY AIPLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCYMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS THIS FORE,