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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY �1 NEW PERMIT [—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE REM 2 INTERIM PERMIT ❑ a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G EIRO y 05A =L 9 - 1452 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a Z B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAYIYEAR) 5 D. TANK CAPACITY IN GALLONS: 12, ,IANC) ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1�� A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Ella REGU R 8 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT O IOPREMIUM a GASAHOL ❑ 7 METHANOL ❑ UNLEADED D9 JOTHERL(DESCRIBE IN ITEM D. BELOW) 2 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED OWIF� pl-JS C.A.S.—#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC,AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF LY`J 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ l SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ a STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ® 6 UNLINED95 UNKNOWN 99 OTHER LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES)( NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP EA K FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER r E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) T IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A ID 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U ♦ FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A DB 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING ❑ MONROIi1NG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 1)s 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 56 a AUTOMATIC TANK GANGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ® 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U AD(MO/DAY/YR) 2 ESTIMATED ANTTANK FILLED WT SUBSTANCE REMAININGF (v GALLONS 3 WASNERT MATERIALI?H YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME �� p (PRI51GNAT.FEI� C"�y DATE NTF.8 &1279:5:j LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DA m = S PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORME (12.91) FILE THIS FORM WITH T LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATIONS