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14F4Un C C STATEOFCAUDRMA is STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s o C.tr OI N,N COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I D DBAOR FACILITY NAME WHERE TANK ISINSTALLED: 1d1ew11d Market I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: 550 IL TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 10UNLEAO D BPREMIUM REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 4 GASOHOL ❑ 2 PETROLEUM O BD EMPTY ❑ 1 PRODUCT ❑ 1eUN UNLEADED © 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED © gg OTHER (DESCRIBE IN REM D. BELOW) D. IF(AA)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Unknown C.A.S.8: �J� 1V �,/ Cp��v.x• 23. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D "/ryA/FLL1U�/K� r� ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE Of99 OTHER SYSTEM F-12 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP ❑ (PrimOryTank) ❑ D BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Cf95UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 5 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 a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Alvs UNKNOWN A U 99 OTHER ❑ D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR E] 2 UNET*HTNESSTES71NG ❑ 3IAONBORING E]NILKbilliAL 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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 LA T USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ � n k n o w n SUBSTANCE REMAINING IU n k n O W n GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME NT &44t w A / DATE IRRIEn 491GNATUREI Surendra F . Pater 9/5/91 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �� #� 2 COUNTY# JURISDICTION# FACILITY It r TANK L-L—� �J�GEIU J STATE I.D.# PERMIT NUMBER PERMITAPPROvbj BY/DATE PERMIT EXPIRATION DATE T. '7 Za FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROOX6M