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• i MA lc-�\-oy o ai;II N y rd ,oj,3�oN •,.:,.. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 1I �R IoH UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �I NEW PERMT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE MARK ONLY ONE REM 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-/SPECIFY IF UNKNOWN A OWNERS-TANK I.D. I� T 5 1 7 B. MANUFACTURED BY: C. DATE INSTALLED(MGDAV/YEAR) D. TANK CAPACITY IN GALLONS: V IL TANK CONTENTS IF A-T IS MARKED.COMPLETE ITEM C. a REGULAR UNLEADED 3 DIESEL ❑ B AVIATION GAS A ❑ I MOTOR VEHICLE FUEL ❑ 4 OIL B. C- Z PR UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT ❑ Ic mWAUDE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT Ftle-195 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED o 99 OTHER(DESCRISEINTTFMO.BELOM D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: E 17 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �� SINGLE WALL ❑ 6 SINGLE WALL IN A VAULT ❑ 99 OTHER 4 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FFIP MATERIAL ❑ 5 CONCRETE (PdMarYTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C.INTERIOR 17_1 ❑ g UNLINED �95 UNKNOWN ❑ 99 OTHER LINING OR ❑ s GLASS UNING , COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ,.❑ 22 COATING ❑ 3 VINYL WRAP ❑ 4" FIBERGLASS REINFORCED PLASTIC CORROSION u y�T g1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTEcno.N" ` SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,8T0. DROPTUBE YES_ NO STRIKER PLATE YES NO__ DISPENSER CONTAINMENT YES__ NO___ IV.PIPING INFORMATION- CIRCLE A IF AB�U2 ENOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U suc SURE A U 3 GRAVITYAU 4FLE)BLE PIPING. A.U 99 OTHER B. CONSTRUCTION A U SINGLE WALL BLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I B R A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S 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 U 99 OTHER 1 4EtN ,N URE LUX ❑2 UNE i0H 5 ❑3 UNaNIXU!I IEW aR�L ❑ REC1a0NC UA [3 5 AVfOM1TC WW ❑ 99 OTHER A� � D. LEAK DETECTION ❑ omr an_ TEE KONr�NO )FAN pEr9Ci0R slutoovm V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3.MO�NOI MONITOR ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER ❑ g TESTING ❑ 1VISUAL CHECK ❑ RECONCIUATION ^�^ ❑ 7 MONRITORIONG INTERSTITIAL ❑ B SIR ❑ 9 TANK IMN GAL ❑10 TES GY TANK ❑ 95 UNKNOWN OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2 ESTIMATED QUANTITY OF 11 111 '1" 3..WAS TANK FILLED WITH YES ❑ NO 1 ESTIMATED DATE LAST USF?D(MOA)AV/YR) SUBSTANCE REMAINING _GALLONS INERTMATERIAL? .✓L I THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDDGE,EIS TRUE AND CORRECT TANK OWNFA'S NAME � /D 0 (PRINrFDd SIONANRE7 /' C LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK k COUNTYM JURISDICTION F FACILITY N �K STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE S.THIS FOR THIS FORM MUSTSHOULD BE ACCOIMPABY ANIED BY AIPLOT PLAN FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U DERGR UND STTORA EE ANK REGULATIONS