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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B w COMPLETE A SEPARATE FORM FOR/.ACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT CI 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TAN! DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ;;I I+-y' Iq 1 /544 77 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.0.# ,0l, ..!`14.2 -.tM S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) lev"i 0. TANK CAPACITY IN GALLONS. /1°95�`�� Ii.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. [� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UMEdOED 3 DIESEL U 6 AVIATION GAS b PREMWM UNLEADED 4 GASAHOL ❑ 7 METHANOL f7 2 PETROLEUM C:] 80 EMPTY 1 PRODUCT t 1c MIDGMWE UNLEADED 5 JET FUEL ❑ 8 M65 ® 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 LEADED 99 OTHER(DESCRIBE IN REM 0.MOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S x ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF CE 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEA ® 5 INTERNAL BLADDER SYSTEMA ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 2 3 FIBERGLASS ® 4 STEELCLAO W/FIBERGLASS REINFORCED PLAS11C MATERIAL ❑ 5 CONCRETE ® 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100%METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ® 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ® 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 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 PROTECTION ❑ 5 CATHODIC PROTECTION ED 91 NONE ❑95 UNKNOWN ❑ OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILLENTION EQUIPMENT INSTALLED(YEAR) 4141:F DROP TUBE YES NO 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A u 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) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100%METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 L�rauueeAl.UKE I� ❑2 UNF TWMffSS 3 xaralsanAL ❑4 a.�Iac U NE 0 5 AUTOMAnG am ❑ OTHER trETECTba TESM 1WNTCRM LEAK OVEM V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 MANURCILIAS ON ENTORY r73 VAIDOZE MONITORING IS A 4 AUTOMATIC TANK ❑5 GGAUGING ROUND ❑6 ANNUALTESTING A 7 CONTINUOUS CONTINUING INTERSTITIAL ❑ 8 SiR ❑ 9 T ANK �IN� ❑t0 MONTHLY TANK ❑ 95 UNKNOWN ®99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT mosum IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOKIEDC,E, IS TRUE AND CORRECT TANK OWNERS NAME / T/,y DATE •(� j RiNTEO^ A r1 I yte !vi/ � 11ix LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER I OS OF THE FOUR NUMBERS BELOW 0,� COUNTY# JURISDICTION# FACILITY# TANK# fjO c STATE I.D:# = - ILI PERMIT NUMBER PERMIT APPROVED SY/OATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUr!"^ON-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED.FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' 'gGROUND STORAGE TANK REGULATIONS FORMS (6-95)