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I STATE OF CALIFORNIA J �" STATE WATER RESOURCES CONTROL BOARD 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 ❑ 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED A Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: *�p.I-I Ik L.U.L-) CA( -.1 F' - >JI q yOlJfpl- CERN �s� CJ 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAWYEAR) V�K(J N D. TANK CAPACITY IN GALLONS: 860 ILTANKKpCONTENTS IFA-11S MARKED,COMPLETE ITEM C. e 1 MOTOR VEHICLE FUEL 4 OIL B. C. LQ 1aUNLEAD REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS A. !—' ❑ ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY v 1 PRODUCT ❑ tb PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM 51—Z 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT ULTEDTANK) ❑ ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL RETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP ❑ 5 CONCRETE - (PrlmaryT9nk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99..Oh1ER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPO% LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER '4�T., LINING S, IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? 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) N A OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) N ♦� "' IV.PIPING INFORMATION 1 CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUNO BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 WI 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 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATICLINELEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING / � MON80flING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED""ENTITY OF 3.WAS TANK FILLED WITH YES NO❑ SUBSTANCEREMAINING GALLONS INERTMATERIAL? ; THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A TO THE T OF MV,KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME f DATE �C ^ IPRINTEO4SIGNATURE) cam✓ Y LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �TAN�K# ��,- STATE I.D.# -5A = � Il zL7-11f �m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. '/q