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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 752404 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ff 5 CHANGE OF INFORMATION ❑ 7 FERMAN SED ONSRE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TAN EM D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AjgpOgT SHELL I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 7524-04-SRU-1 B. MANUFACTURED BY: RHEEM C. DATE INSTALLED(MOIDAYNEAR) 1973 D. T-NK CAPACITY IN GALLONS: 10, 000 ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. yyyy1� 1 MOTOR VEHICLE FUEL 4 OIL S, C 1a REGULAR n 3 DIESEL ❑ 6 AVIATION GAS A q:•I ❑ 7yP UNLEADED Iu6i y GpgAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT _IL�JI 1b PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O UNLEADED ❑ Be JOTHERL(DESCRIBE IN ITEM D. BELOW) 2 LEADED ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM )EXI 2 SINGLE WALL [D4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER )L B. TANK � 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.CORROSION ❑ 1 IIET14YLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE K295 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A&)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A40 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)A 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK�2 INVENTORY RECONCILIATION [:] 3 VADOZE MONITORING"$4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING a TANK TESTING 7 INTERSTITIAL MONITORING E:] 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENH TY OF P JURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAM pp7 7 �� IPRINTE(1a SIGNA I / LOCAL AGENCY US ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / COUNTY# JURISDICTION# FACILTANK# -T K AELI I' STATE I.Dl ffV#71AW PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT E IRATK)N DATE -a FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FOR S N FILED. FORU9MB-RS