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F504wCCS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "- I - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (,EVVEy_e FANO I L LTp• PA WN61-Su I P I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.I B. MANUFACTURED BY: TP-v sc� C. DATE INSTALLED(MO/DAYNEAR) :Ytj IJ67 19,91 D. TANK CAPACITY IN GALLONS: 6100 D 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 2<1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 41a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 1 PRODUCT ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BD EMPTY17r ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E� 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N Ill. 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 LINER ❑ S INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 1] 3 FIBERGLASS 2<4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W1FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 5�_6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°.6 METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP � 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC. DROP TUBE YES NO STRIKER PLATE YES_ _ NO DISPENSER CCNTAINMENT 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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)AU 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I MECR WICAL LINE LEAK 2 UNE r.HTNES5 CONTINUOUS INTEASTIM 4 ELECTRONIC UNE AUTOMATIC PUMP ❑ 99 OTHER D. LEAK DETECTION D€TECTOR ❑ TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ��y ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION ORY ❑ 3 VADOZEMONITORING '—"4 AUTOMA IC TANK 1❑ 5 GROUNDWATER ❑ 6 TESTINGTANK 7 CONTINUOUS MON TOR NG INTERSTITIAL ❑ 6 SIR ❑ TANK GAUGINGMANUAL 1❑10 TO TINGY TANK ❑ 95 UNKNOWN 7-199 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) IVR P STIMATED DATE LAST USED(MOIDAYIYR) -- 2-ESTIMATED QUANTITY CF �-- 3.WAS TANK FILLED WITH�T ❑ E NO l SUBSTANCE REMAINING GALLONS INERT MATERIAL T � THIS FORM HAS BEEN COML E UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNE ; NAME I ► 1�CX�-_ +f DA� (PRINTED fi SI ATURE) LOCAL AGENCY ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#'j rjcl. TANK# STATE I.Dl 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. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE VWGROUND STORAGE TANK REGULATIONS FORM B (6.95)