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STATE GF CALIFORMA ' s STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITEr ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a A TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5cv-rH LAND "EILzv aZ 9,143 S. I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) .4—Oj`I D. TANK CAPACITY IN GALLONS: 10 01150 ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. �y A r O% MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. liREGULAR UN EADED 3 DIESEL ❑ 6 AVIAT0N GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1DPREMIUM e 4 GASAHOL 7 METHANOL ❑ ❑ ❑ ❑- 3 CHEMICAL PRODUCT 85 UNKNOWN ❑ 2 WASTE UNLEADED 5 JETFUEL2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.e: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,ANDC,ANDALLTHATAPPLES INBOXDANOE A. TYPE OF 4� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS W 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INLININTERIOR G❑ 5 GLASS LININ6 UNLINED ❑ 95 UNKNOWN E] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A#*2 PRESSURE A U 3 GRAVITY 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 i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A ' 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 00 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGMONROIUNG ❑ 99 OTHER V.TANfi LEAK DETECTION ISUAL CHECKINVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑1 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING �INTERSTITIAL MONITORING ❑ 81 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT A"LICANTSNAllE r DATE IRRINTEOaSIGRATUREI1 �I i M�`e ,/J�// v_ I 1r KY4./ 1 1 / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBE OW ` L COUNTY# JURISDICTION# FACILITY# TANK# STATE 104m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM B (12 91) FILE THIS FORM WITH THE AL AGENCY IMPLEMENTING THE UNDERGROUND STOR TANK REGULATIONSyu