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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD yv� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B e , 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 ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ai1CC 'vIaC7 (ons JrO C.V� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.t B. MANUFACTURED BY: I�212 XeS C. DATE INSTALLED(momAYNYEAR) 3 ,tn 9� D. TANK CAPACITY IN GALLONS: 2O i✓r J IL TANK CONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 29-1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ ❑ lc MIDGRADE UNLEADEDO 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCIME N ITEM D.BBON) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF )C� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNEP ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT I' ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL iuI 3 FIBERGLASS ❑ 4 STEEL CLAD WL FIBERGLASS REINFORCED PLASP.0 MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pmmy Tank) ❑ 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 UNIG [7r 6 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 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 ❑ OTHFJR PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN 99 SPILL CONTAINMENT INSTALLED(YEAR) OVERRLLP ENDON EQUIPMENT INSTALLED(YEAR) E SPUN AND OVERRU H:TC. DROP TUBE YES NO_ STRIKER PLATE YES NO_ DISPENSER CONTNNMENTNT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Ate)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A`U�2 DOUBLE WAIL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U t BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A CLFIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATIG A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 ISI CATHODIC PROTECTION A U 95 UNKGWN A U 99 OTHER D. LEAK DETECTION 1 IwICANru urE LENc ❑2 ZTlomaF.ss 3=TROD� ❑4 Bccl CC IX s nc wP ❑ 99 mmm V.TANK LEAK DETECTION ANNUAL ❑ 1 VISUAL CHECK ❑ 2 MANUAdLIATIONORY ❑ 3 MA TRIG 1:34 AAUUTOMAG C TANK ED GROUND MONITORING ❑ 6 TESTI GTANK RECON7 CONTINUOUS INTERSTITIAL8 SIR ❑ 9 WEEKLY Al1 UAL ED 10 MONTHLY TANK E-] 95 UNKNOWN ❑ 99 OTHER MONITORING T VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOMAYNM 2.ESTIMATED OUANTT'OF 3.WAS TANK FILLED WRH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME - DATE �)`Z (PRNim&9 TuBE) 7r, �va LOCAL AGENCY USE ONLY THE STATE LD.NUMB6IS COMPOSED OF THE FOUR NUMBERS BELOW COUNT'A JU�RISmDICMN R �FACILITY 0�, TANK If STATE I.D.# PERMIT NUMBER PFAA9T APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AgdIkATION-FORM A UNLESS A CURREM FORM A HAS BEEN FLEQdWm C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLdW RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGIWOERGROUND STORAGE TANK REGULATIONS FORMS (6-95)