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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B dam, i , . 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# VQ (- Kr)cc.kouf -T'ank B. MANUFACTURED BY: U rl k�'VIO Lk)VY C. DATE INSTALLED(MO/DAY/YEAR) A (-%1 ocde I I 'j "!-}+ D. TANK CAPACITY IN GALLONS: S DO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tO MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 6 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ® WASTE ❑ 2 LEADED Rl 99 OTHER(DESCRIBE IN REM D.BELOVl) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I',., 1 `-u e UAC4fjItIL, +0( C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �¢�I 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Cfl 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 WIFRP (Primary Tank) ❑ 9 BRONZE E::] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ® 99 OTHER 4�n C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ®�91 NONE ®95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSC. SPILL CONTAINMENT- JNSTALLED(YEAR) ' OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO K 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 2PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A LOA 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 A U 9 UNKNOWN A U 99 OTHER D. LEAK DETECTION [::]1 MECHANICAL UNE LEAK 2 UNE 710KNESS 3IXm CNVWS INTETISTMAL 4 ELErMKNIC LINE 5 AIROWTIC PUMP DETE=8 ❑ TESTING MONITORING LEAK OETECTOR SHUTX M ® 99 OTHER BG V.TANK LEAK DETECTION Grm•n eol ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUNDWAMONITORINGTER F76 TANK TESTING ❑ 7 MON CONTINUOUS INTERSTITIAL E] 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ® 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) $e De4&/A,l0' 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH - SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE /J (PPI EDa SIGNATURE}� /-- I I H - y' �I.ISCI(1 / llUY121i IPS 1.. V '1-- /1'7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# r'I STATE I.D.# l 5 el PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM MUST BE ACCOMPANIED BYAPERMIT APPLN•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED, MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS 95)