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• � `ya, coc . STATE OF CALIFORNIA i d®y1•' �, STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 8 TANK REMOVED L NEW PERMIT d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE HARK ONLYONE REM El INTERIM PERMIT ❑ 10 W 6 ^ Imo"f 41;Inaw1 d£ LOC DBA OR FACILITY NAME WHERE TANK IS INSTALLED:S' LL I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: IA A OWNER'S TANK I.D.& D. TANK CAPACITY IN GALLONS: 11 C. DATE INSTALLED(MOIDAWYEAR) K.nSb COMPLETE MC. 6 AVIATION GAS IF AA IS MARKED, II.TANK CONTENTS Q ❑ t&REGUIUNLEADED E] 3 DIESEL El OIL B. ® tb PREMIUM UNLEADED ❑ l GASAHOL ❑ T METHANOL A ® 1 MOTOR VEHICLE FUEL 1 PRODUCT tc ❑ BO EMPTY ❑ ❑ MIDGRADE UNLEADED ❑ 5 JET FUEL El B MBS El2 PETROLEUM 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBEWREY D.Ba0W1 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ C.AS.8: D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX a SE INTERNAL BLADDER SYSTEM ® 95 RdONOLVN El DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNEP ❑ 99 OTHER A. TYPE OF ❑ d VAULT SYSTEM E] 2 SINGLE WALL SINGLE WALL IN A ❑ I ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK BARE STEEL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 10096 METHANOL COMPATIBLE W MATERIAL � 99 OTHER (PNmwy TInk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN C.INTERIOR ❑ 1 RUBBER LINED E] 2 ALKYD LINING E] 3 EPDXY LINING ❑ 6 PHENOLIC LINING LINING OR ❑ s cuss LINING ❑ 8 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 ❑ 6 FIBERGLASS REINFORCED PLASTIC CORROSION © PROTECTION 95 UNKNOWN ❑ 99 OTHER ❑ 5 CATHODIC PROTECTON 91 NONE❑ SPILL CONTAINMENT INSTALLED(YEAR)&AJv�IKE `I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) CU N E.SPILL AND OVERFILL,etc. DROP TUBE YES__ ND__ STRIKER PLATE YES__ NO_ DISPENSER CONTAINMENTNT YES 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 d FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A A 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°6 METHANOL COMPATIBLE WffgP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Aa 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I NEcw++lcu ME LFAx ❑z 11xE ncHDEss ❑3 caxleNous NTBurmN d ecclBxnc urA ❑5 AVIOMLBc PULP OEiELfOR TE51NG 40NiDPMG !FA[RTECfOR 9u10OWN ® 99 arae glib a U V,TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ z RECO ANNUAL UAL— RECONCILIATION ❑ 3 MAODOZENIITORING ❑ d ALTO�GAUGWGnC TAM( ❑5 MONITORING7� ❑B TESTINGTANK ❑ 7 MONITORINGINTERSTITIAL ❑ 6 SIR ❑ 9 TREK GAULY GING ❑ 10 TESTING TANK © 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF � ('1 3.WAS TAM(FILLED WITH YES ® NO SUBSTANCE REMAINING % GALLONS INERT MATERIAL 7 a THIS FORM HAS BEEN COMPLETED UNDER PENAL ER4&q,A D E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAM � �' DATE (PRINTED&SIGNATURE) V ' _1 L-6Nta 8 z4 A8 LOCAL AGENCY USE ONLY THE STATE LD.NU BER IS OSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY e JUV61CTiON M FACILITY x GSL TANK# PERMIT NUMBER m v 1i PERA9T APPAUL Ep BY/DATE TR/9FORMMOSTBEACCOMPAN/ED BYq pERMR'APPL/OA]7ON BYAP(OT - SR000OBEACCONPAB7EDpLU F7 MA A FORME(6-95/ IN /, sPORy THEELOC�fty8 *Z44%/40IHs7 �I,