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STATEOFCAUFORNA • :�'� s)\ • STATE WATER RESOURCES CONTROL SO ARO UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY r7 A NEW PERMIT ❑ 0 RENEWAL PERMIT C::] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSc0 ON-SITE U ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ s TEMPORARY TANK CLOSURE /❑ B TANK REMOVE 02r 08AOR FACILITY NAME WHERE TANK IS INSTALLED: 461 d !� 2G ( 'L l';7 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN U.A^ A. OWNERS TANK I.0.1 I B. MANUFACTURED BY: ek C. DATE INSTALLED(MGOAYIYEAR) C7 J I D. TANK CAPACITY IN GALLONS: �Q—D II.TANKCONTENTS IF A.I IS MARKED.COMPLETE ITEM C. I� A. ❑ 1 MOTOR VEHICLE FUEL ❑ A 06. a. C. ❑ I&REGULAR u 2 DIESEL ❑ S AVIATICN GAS ❑ 2 PETROLEUM ❑ 0o EMPTY ❑ 1 PRODUCT ❑ IO PREMIUM LJ a GASOHOL ❑ 7 METHANOL UNLEADED S JET FUEL ❑ 0 CHEMICALPROOL'CT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 99 OTHER (DESCRIBE IN ITEM 0. BELOW] 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.9: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.S.ANO C.AND ALLT14AT APPLIES INBOXD A. TYPE OF ❑ I DCUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 2 FIBERGLASS ❑ A STEEL CLAD 'NI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE'NIFRP (kimNy Tank) ❑ 9 BRONZE Cl 10 GALVAN12ED STEEL ❑ 95 UNK40M ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ S EPDXY LINING ❑ A PHENOLIC LINING C.INTERICR F--j S CLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 5 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 3 CATHODIC PROTECTION Q 91 NONE ❑ 95 UNKNOWN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGRCUNDOR U IFUNCEACROUND.BOTHIFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 2 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A V 2 DOUBLE WALL A U S LINED TRENCH A U 9S UNK40WN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 2 PCLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A V B 100% METHANOL CCMPATISLEWjF9P PROTECTION A U 9 GALVAN2EO STEEL A U 10 CATHCOICPAOTECTICN A U 95 UNKNOWN A V 99 OTHER 0. LEAK DETECTION ❑ I AUTCMATCLNELEAKOETECTCR ❑ 2 LINE TIGHTNESS TESTING ❑ O YCNRORWG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ I SUAL CHECK 2 INVENTORY RECONCILIATION ❑ 2 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MCNITCRING 6 TANK TESTING ❑ 7 INTERSTITIALMONITORING C] 9T NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED OATS LAST USED(MOIDAYNFI) 2.ESTIMATE000ANTRYOF O.WASTANKFILLEO WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FCRM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE ✓1 7 IvaxrEoaswwtunfl ry. .._f / � LCCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW !l L- COUNTY x JURISOICTICN x FACILITY x TANK x STAT I.D.n FTTI lolo I ilD U� PERMIT NUMBER 'PERMIT APPROVED BYAGATE PERMIT EXPIRATION DATE FORMS 19.901 THIS FCRM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR09114R5