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ax y • �3��\m1� to-�\-oN �212� STATE OF CAUFORNIA I, (� .. STATE.WATER RESOURCES CONTROL BOARD TL 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM �2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE a 0 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LO /Ply o,6-,,73 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN p OWNER5 TANK I.D.# 81 S ZyS B. MANUFACTURED BY: AJ C. DATE INSTALLED(MO�OAYA'EAR) D. TANK CAPACITY IN GALLONS: C) II.TANK CONTENTS IF A-T IS MARKED,COMPLETE ITEM C. A REGULAR UNIFAO 3) 3 DIESEL ❑ 8 AVIATION GAS A [71 MOTOR VEHICLE FUEL ❑ 4 OIL 0. C. 1G PREMIUM UNLEADED 4 GASAHOL ED7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1c MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE INNEMO.BELOW) 3 CHEMICAL PRODUCT CO- 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX,D AND E ❑ i DOUBLE WALL ❑ 3SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER SYSTEM EEpj SINGLE WALL �U BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK ❑ g POLYVINYL CHLORIDE E::] 7 ALUMINUM LlB 1DO% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (PTMMY T#Rk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F-12 ALKYD LINING L] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ g UNLINED �A5 UNKNOWN ❑ 99 OTHER LINING OR r75 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 1008 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4' FIBERGLASS REINFORCED PLASTIC CORROSION � ��--��//g'1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTIOry�I� SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL.ESR NO STRIKER PLATE PLO— DISPENSER CONTAINMENT YES_ NO DROP TUBE YES__ IV.PIPING. INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U14�A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING. A U. 99 OTHER B. CONSTRUCTION A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 1008 METHANOL COMPATIBLE W/FRP PROTECTIONA U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER c 1 MECXNACIL LPIE LFJJ( 2 UNE IGHTNE55 ❑3CO`IM1�S WIEPSIOW ❑4 ELECTRONIC WE ❑5 AT MW 99 OTHER D. LEAK DETECTION ❑ ❑ TESTNa IEKK rIETEcroR pETELTOR V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3.VADOZE ❑ 4 AUTOGAUGMAT C TANK ❑ 5 MONITORING GROUND ❑ 5 TESTING ❑ 1 VISUAL CHECK ❑ RECONCILIATION %WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ,OTHER ❑ 7 MONRORIONG INTERSTITIAL ❑ B SIR ❑ TANK GAUGINGTESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ❑ LEr- 2 ESTIMATED OUANTRY OF //I 1/ 3.WAS TANK FILLED WITH YES NO 1 ESTIMATED DATE LASTU�SFjD�(MO/DAY/YR) SUBSTANCE REMAINING �LGALLONS. INERT MATERIAL? ✓( THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLEDDDATE TRUE AND CORRECT TANK OWNERS NAME /O (PRINTED d UGNAWRE) / C LOCAL AGENCY USE ONLY( THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION 3 FACILITY# STATE LDA m PERMIT NUMOER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE THIS FORK MU SHOULD BE ACCOIMPANIED BY AI PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDECOMPLETED STORAGE THIS FOF