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IaIi31dN •.•..:...•� STATE OF CALIFORNIA 00o STATEWATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;eo. 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT 1:13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE MARK ONLY ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LO Pk t;-,,73 a 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN K B. MANUFACTURED BY: A OWNERS'TANK I.D.R G DATE INSTALLED(MdDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-415 MMKED,COMPLETE REM C. to REGULAR UNLEADED 3 DIESEL ❑ 5 AVIATION GAS A ❑ I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ a M85 ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN IfEMD.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNOXYWN A.TYPE OF 2�__,,.ry�� ❑ ❑ 99 OTHER SYSTEM A�7�A SINGLE WALL 4 SINGLE WALL IN A VAULT B. TANK _Q:j BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Pdmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 9 UNLINED �DS UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4' FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTIOy.s� SPILL CONTAINMENTINSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,etc. DROP TUBE YES__ NO STRIKER PLATE YES— NO_ DISPENSER CONTAINMENT YES__ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTHIFAPPUCABLE A. SYSTEM TYPE A U BUD A U 2 PRESSURE A U 3 GRAVITY A U a'FLEXIBLE PIPING, A�U 99 OTHER B. CONSTRUCTION A U SI GIEWALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 B A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U s ALUMINUM A U a CONCRETEA U 7 STEEL Wt 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 MLCHNacu uxE LMK ❑2 UNE TaK s ❑3 caxtwrous NIEASRML ❑4 B>:cmoNo uxE ❑s AuroMAno Puw ❑ 99 oTH19I �IZ"u✓ D. LEAK DETECTION ❑ omwo TESTa+o WNTMM tTAN OEIECTOR sluToowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK L[�DS ANUALI INVENTORY ❑IATION 3 VADOZEMONITOLNG ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND TER ❑a TESTING 7 CONRNUOUS INTFRSTRIAL SIR ❑ 9 WEEKLY MANUAL ❑10 TENTHLY TANK ❑ 95 UNKNOWN �c♦)B OTHER ❑ MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2 ESTIMATED QUANTITY OF (�/y��/ 3..WAS TANK FILLED WITH YES ❑ NO� 1 ESTIMATED DATE LAST,N�,(COIDAY/YR) SUBSTANCE REMAINING��-GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND T,vnncC TANK OWNER'S NAME 61 (PPWTFDa51BNATUBkT �` C LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 4 FACILITY a TANK a STATE LDA m �] � = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE % HAS BEEN FILED. FORM THIS FORM MUSNOUIDBOACCOST C DIED BYADBYAPLOTPLAN.APPLICATION -FORM FORMUNLESS WITHTHELOCAL AGENCYMPLEMENTING THE UNDERCOMPLETED GROUND STTORAGETA K RITHIS FOR MUST BE EGULATIONSNS. ILE