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STATEOFCAUFONNIA STATE(RATER RESOURCES CONTROL BOARD ��_ ° UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ? °B 'p COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ ] RENEWAL PERMIT S CHANGE OF INFORMATION T PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 WTEWM PEAEI'T ❑ A AMENDED PERMIT 6 TEMIOMRT TANK CLOSURE B TANK REMOVED Ar DSA OR FACILITY NAME WHERE TANK IS INSTALLED: I 1. TANK DESCRIPTION COMFLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWBEA'S TANK I.D P S. MANUFACTURED BY. r C. DATE INSTALLED IMO'DAV/YEAP) ,5 D. TANK CAPACITY IN GALLONS I JOO II.TANK CONTENTS IF A-1 IB MwRKDD.COMPLETE AM C. ❑ I MOTOR VEIBCLE FUEL ❑ A OIL B. G to PEOUTAR VN{EApEp O i DIESEL ` I 6 AVIATION GAS A I� 1D M04LM UTAEAOFD ❑ A GASAHOL IL�oI T METHANOL 2 PETROLEUM ❑ w EMPTY ♦GJ I PRoGuG ❑ IF MOORME N/FAD® 9 JET N0. 6 M55 �f❑++ ] CMELMCAL PROOVCT ❑ 99 UNIWOWN ❑ 2 W/16TE 2 LEADED VY mw WESCWpE W REM D.B601M D. 19(A 1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C A.S.9' IA, TANK CONSTRUCTION MARK ONE ITEM ONLY IN PDXES A 0.AND C.AND ALLYMAT APPLIES IN BOX D NIDE F7I DOUBLE WALL ❑ 9 WHOLE WALL YVT EXTERIOR LINER ED BL 5 iNTERNAADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF 99 SYSTEM 2 SINGLE WALL ❑ • SINGLE WALL IN A VAULT OTHEa B. TANK Lif 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ i FIBERGLASS ❑ A STEEL CUD Wa FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ S CONCRETE ❑ B POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B IW%METHANOL COMPATIBLE WIFAP (Plimay Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 99 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ i EPDXY UMNG ❑ A PHENOLIC UMNG LINING OR ❑ 5 GLASS LINING ❑ 6 UNUN660 �B6 UNKNOWN ❑ W OTHER COATING IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP = 2 COATING ❑ i VINYL WRAP a A FIBERGLASS REINFORCED PLASTIC CORROSION9KN9B 1 NONE ❑95 UNKNOWN ❑ OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILLCONTNNMENT INSTALLED(YEA OVER F�LI PREVENT( N OVPMENT INSAINYEA 7 E SPILL AND OVERFILLA PTC. DROP?UDE YES NO STRIKER PLATE YES— NO DISPENSER ER CON CONTMNMEN YES Np IV,PIPING INFORMATION CIRCLE A W ABOVEGROVNOOR U IF UNOERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 7 GRAVITY A U A ilEXIpLE%PING A U W OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 3 DOUpLE WALL A U ] LINED TRENCH A U 96 UNKNOWN A U Ev OTHER C. MATERIAL AND BARE STEEL A U 2 STAINLESS STEEL A U i POLYVINYL CHLORIDE(MCIA U A FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U T STEEL WI COATND A U 6 1007-METHANOL COMPATIBLE WAFRP PROTECTION A U P GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION O 2 ONIR.pR wlLon111M a A RECIPRIIc LAK( F—I s MMtgN+C FMA• vy�� CEHCroo TLfnFp WIII9ANB LWI OFTEfIW 4J g6R99FM V.TANK LEAK DETECTION ��^^'TI 2 MANUAL INVENTORY O ] VAOO$E • GA AUTOMATIC?MNK S GROUND WATER 9 ANNVAL TANK ❑ t v15W1 CHECK LJ AECONCAIATION NONITORINO GAUGING ❑ MONITORING ❑ TESTING ❑ T MO»� TESTING tMU U NTERSMIAL ❑ 9 pIR ❑ 9?WEEKLY MANUAL ❑Ip MONTHLY TANK 5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I ESTIMATED DAT LAST"IcAboUSE (MOMAYNA) 2.ESTIMATED OUANTITY OF� SWASTAN%FlLLERIAL7 YES NO ED SUBSTANCE REMNMNG GALLONS INERT MATERIAL T THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TN+K ON^ RS NAME -/VLOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF T"WL COUNTYA JURISDICTION 9STATE 1.0.#PERMIT NUMBER PMIT wPPROV60 BYIDATE FUIL FOR TKIS FORM MUS��CE PANTED BYIA EPERMIT AP LIAP FRE THIS FORM WIT�II TNELOCAL AGENCY MPLFMRENT FORM&MS ENTIIKr iNE1MDEKGROIMD STPS C MET lit CODYRPLILG�AN REGULLAATAIONS THIS FORM FORME Is 951 1`2fT Iwo (f _(