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STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , R I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ,7 ❑ X ..J 66 TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: tyf 1 lal Ij1 J "TLA501 S -PC I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.a 1'7-52A — B. MANUFACTURED BY: TOJSJ �oy)jla'nrjgyTt C. DATE INSTALLED(MO/DAYNEAR) HO Ig D. TANK CAPACITY IN GALLONS: 'D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. R❑D� 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F-12 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT l� lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL E::] lc MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN DEMO.BELOW) D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: 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 ® I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT El 99 OTHER B. TANK 1✓l 1 BARE STEEL Q 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 54 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100-A METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE F-1 95 UNKNOWN ❑ 99 OTHER AAtq E SPILL AND OVERFILL,etc. SPILL CONTNNMENT jNSTALLED(YEAR) OVERFIL6fHEVEN I ION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT 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 02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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 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 STEELW/COATING A U 8 100% METHAAN"OLCOMPATIBLE�WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A THGc 99 OTHER LLIIW YY)Yi-LLKiI-Aii 1 wc—. M UK LEAK 2 MME M. NEn 3 LON M=S WTERSTmAt 4 EIFCMi M UNE 5 AUf01MRt WI.fl D. LEAK DETECTION oETEcron ❑ TEsnxa MON 1110 ❑ LEAK X712cmn ❑ sNUT C ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MONIITORING `f"' 4 GAUGING MONITORING TANK ❑5 GROUND MONITORINGTER ❑6 TESnNGTANK 7 MON TOR U INTERSTITIAL El SIR ❑ 9 WEEK LY MANUAL ❑ 10 MONT HLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 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 - 'H Lj�+ SNI C7 DATE (PRNTED A SIGNATURE) Its (J,1� ff��T r LOCAL AGENCY USE ONLY THE STATE I.D.NUM IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION# FACILITY X 00-7l/] TANK A STATE I.Dl m 2-131 / Z 3 3 D 7j'? jjcl L -o/ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLK'-")N-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOR"C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B95) ,ulFf�fg8 �