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�Aso�,...'co STATE OF CALIFORNIA WP +� STATE WATER RESOURCES CONTROL BOARD �� ,m UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B > _ , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS L- SPECIFY IF UNKNOWN A OWNERS TANK I.D.0 VQ knC-kOL(-" tLn 'k- B. MANUFACTURED BY: u rlL)owvn C. DATE INSTALLED(MOIDAYNEAR) TY IN GALLONS: 500 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ® WASTE ❑ 2 LEADED 89 OTHER(DESCRIBE IN REM D.BEL01"!I D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED w C.A.S.p 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM E'I 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ,cy 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ® 99 OTHER aiLll�ry C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED Ez 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑L„t NONE 2 COATING ❑ 95 UNKNOWN 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ ® ❑ 99 OTHER PROTECTION 5 CATHODIC PROTECTION ®oj SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BSC. DROP TUBE YES X 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 89 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U(9) UNKNOWN A U 99 OTHER 1 MECHMIIC9L UNE LFAp 2 UNE BGHfNE55 3 WNnMIWS INTERSTIIUL A ELECIRGNIG NNE ❑5 AU=11 PUMP g9 OTHER TCS �G D. LEAK DETECTION ❑ G UOg ❑ TFsrNG ❑ uoNTGRpxi ❑ tEAN GETEcroR sHUTDowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MECONCILANUAL ❑ 3 MONIITORING VAOZE ❑ 4 GAUGINGAUTOMATI TANK E:]5 MONITORING TESTING ❑6 ANNUALTESTINGGROUND TANK ❑ 7 CONTINUOUS G EK NUO INTERSTITIAL ❑ 8 SIR ❑ 9 WELY MANTESTING UAL ❑10 MOHLY TANK ❑ 85 UNKNOWN ®99 OTHER MON VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 'Be O&el&jvi 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO E]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 ' DATE (PR IN EOd SIGNATOR YL2.ale� r7- j4- 91 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOd2 OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# u TANK# � STATE I.D:# p b ( to h PERMIT NUMBER PERMIT APPROVED BY/DATE ON DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Fpppp��LLC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEW GROUND STORAGE TANK REGULATIONS FORM B (6-95)