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%w Ivo STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Ly I NEW PERMIT a 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY S ON S ONE ITEM O 2 INTERIM PERMIT E::j 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSUREOp`8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �oLi Vi I2Yld 17 �FJ 450 i N � H I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X I -D I B. MANUFACTURED BY: ia' p irI rner%t C. DATE INSTALLED(MOIDAYNEAR) t I D. TANK CAPACITY IN GALLONS: IO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ® 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 1a REGULAR UNLEADED Q 3 DIESEL 0 6 AVIATION GAS A Ib PREMIUM UNLEADED 4 GASAHOL O 7 METHANOL O 2 PETROLEUM O BO EMPTY 1 PRODUCT O 1c MIDGRADE UNLEADED O 5 JET FUEL O 8 MBS O 3 CHEMICALPRODUCT E:l 95 UNKNOWN 2 WASTE Q 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.X 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 O 3 SINGLE WALL WITH EXTERIOR UNER E:] 5 INTERNAL BLADDER SYSTEM C] 95 UNKNOWN SYSTEM I❑ 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT 0 99 OTHER B. TANK L I BARE STEEL O 2 STAINLESS STEEL F--� 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL ED 95 UNKNOWN 99 OTHER C.INTERIOR E:] I RUBBER LINED a 2 ALKYD LINING 03 EPDXY LINING O 4 PHENOLIC LINING LINING OR E:] 9 5 GLASS LINING lq 6 UNLINED E:] 95 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH VXX° METHANOL? YES_ NO— D.EXTERIOR IK I POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E::] 5 CATHODIC PROTECTION O 91 NONE Q 95 UNKNOWN O 99 OTHER SPILLCONTAINMENTI STALLED(YEAR) P OVERFILLEVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,lIC. DROP TUBE YESE NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES-QL_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A 02 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 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRp PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A&) OTHER Hxltle rr3n-w1¢t'2I�E D. LEAK DETECTION 1 uscNANlcx uxE IFAN O 2 uNE TIGNrxEss 3 coxrlxucus INTERSTn1At O s Eu[cmaxrc uxE O 5 AMrownc" O 99 OTHER OEIECIOB TESTING MOMTORING OF OEIECTdi SIXIIW1xN V.TANK LEAK DETECTION --I 1 VISUAL CHECK LJ 2 MANUAL RECONCILIATIONORY 3 VAOZEMONIITORING ® 4 GAUGING AUTOMATIC TANK O 5 GROUND MONITORING WATER O 6 ANNUAL TESTINGTANK 7 MONITORINGOUS INTERSTITIAL 8 SIR O 9 TpNEK GAUGING TESTING 10 TESTINGY TANK O 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a 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 TANK OWNER'S NAME 1u 2n1 b DATE (PRINTED 651GNATURE) / L. N GID LOCAL AGENCY USE ONLY THE STATE I.D.NU661 IS C6POSED OF THE FOUR NUMBERS BELOW V COUNTY k JURISDICTION a FACILITY k C62 Y779 TANK a STATE I.D.# au = IAI*31/ 1-)- 131310 ,q PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ALL II THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUr--ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR"C MUST BE COMPLETED FOR INSTALLATIO S. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P "ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ?GROUND STORAGE TANK REGULATIONS FORM B (6-95) /