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STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD ° UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B °mom, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �7 PERMANENTLY CLOS O TE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: fOfvv\P1 U3nOc..� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# 39- 50so9 -01 B. MANUFACTURED BY: V L n of-)'/\ t\ C. DATE INSTALLED(MO/DAY/YEAFI) IcIz i (1) ID. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL EL C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM BO EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED O 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADEDE UNLEADED ❑ 5 JET FUEL E] 8 M8 2 LEADED ❑ 99 OTHER(DESCRIBE W MD.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.f: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNW40WN SYSTEM I4 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Ip I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 1D0% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED �g 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1WA METHANOL? YES_ NO-. D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ®95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BTC. SPILL CONTAINMENT INSTALLED(YEAR) A OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 IFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I 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 I BARE STEEL 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 STEEL W/COATING A U 6 100% 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 N�cNNacu uxE IFAX 2 IaIE iXYmiE36 D coxrlxuous WIE0.5T114LL A EU:OmaaO UNE s AuroEunc wea ❑ DETECTOR ❑ TESTING ❑ LN)MiGPBlG IFNI DEIECT011 ❑ SH9fWWN ®99 OTHER lL&KaV&aA V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RM CO CILIATIONUAL ORY ❑ 3 MONITORING VADOZEa 4 GAUD NG C TANK O 5 MON TORINGTER r-76 TESTING ❑ 7 MONITORING INUINTERSTTRAL ❑ 6 SIR ❑ 9 TANK GAUGING ❑10 MONTHLY TANK CK 95 UNKNOWN ❑99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE, 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK TILLED VATH n. 1g9p SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME �'"� DATE (PRINTEp A SIGlUTURE) E o K A -s-TO 5 1319{o LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION# FACILITY# TANK M (0 1 STATE I.D.# m U (o ( _qT9_] O I q Lc PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ` I/J THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLA SJTH_I9 FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN -11 THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNP` GROUND STORAGE TANK REGULATIONS FORW316AT FORME (6-95) ` `J