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DMP, STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B la- COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMR ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n_ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE an's TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.p 740-55157 B. MANUFACTURED BY: -/ C. DATE INSTALLED(MOMAYNEAR) 0. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ I PRODUCT to MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 4�_ C.A S.p: 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 ❑��)?A 1� DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN SYSTEM /0SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK _Q:J BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WA=RP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYO LINING ❑ 3 EPDXY UNING ❑ 4 PHENOUC UNING LINING OR ❑ 5 GLASS LINING F76 UNLINED (E�A495 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? 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 CATHODICPROTECnory� SPILL COTRIKER P NTAINMENT INSTALLED(YEAR) OVERFILL PREVENnON EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,SLC. DROP TUBE YES_ NO_ SLATE 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 B. CONSTRUCTION A U SINGLEWALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BRE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100Y. METHANOL COMPATIBLE WIFRP PROTECTION A U G GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER a�� c 1 NECNAMGL UNE LFAC 2 UNE RGHmESS O B CWI INUW4 WTE WIML ❑4 ELE=0MC UYE ❑5 AIIfOMAiIC PUMP ❑ 99 OTHER Nrly�^ 0. LEAK DETECTION ❑ I>ErEaoR ❑ TEsinw wowmw LEAN pEfECfOR sNuroowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY F-13 VOZEMONIITORING ❑ 4 GAUGING TIC TANK ❑ 5 GROUND MONITORING [:] ANNUALTANK 8 TESTING ❑ 7 MOOR NG INTERSTRMAL ❑ 8 SIA ❑ 9 ANKLGAUGINGAL ❑10 TESTING TANK ❑ 95 UNKNOWN .�.$ OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST U /(MOIDAYNR) 2.ESTIMATED QUANTITY OF � 3.WAS TAMC FILLED WITH YES NO SUBSTANCE REMAINING ALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ R AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME � /A1 0 (PRIMEOISIGNANPE) / 6 ((�� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION;F FACILITY# TANK STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE R BEEN FILED. FORM C MUST BE COMPLETED FOR THIS FORM MUST ENT FORM A HAS SHOULD BE ACCOIMPABY ANIED BY AI PLOT PLAN. FILE FTHIS FORM ORM WITH THE UNLESS A CU LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORA E TANK REGULATIONS INSTALLATIONS.THIS FORM FORM B (6.95)