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we,,.cea - STATE OF CALIFORNIA c+� s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ONE REM El2 INTERIM PERMIT AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D.N � 11 B. MANUFACTURED BY: � rcwyl C. DATE INSTALLED(MO/DAY/YEAR) Ic y V Lay' D. TANK CAPACITY IN GALLONS: S V J II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. T- / C, ❑ le flEGUIM UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY cs 1 PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1t MIDGRADE UNLEADED 5 JET FUEL ❑ 8 MBS 3 CHEMICALPRODUCT 5d95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Wi99 OTHE(DESCRIBEINREMD.BELOM D. IF(A-1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E AL TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM � 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK , 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PpnlYTeWW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F❑y2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 1 y1 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100-A METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE 1:395 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION [z II SPILLCONTAINME STALLED F.AR) OVERFI REVOUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BIC, DROP TUBE YES NO ''** STRIKER PLATE VEB - NO DISPENSER CONTAINMENT YES_ NO fy 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 U 9 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U / 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECXAIIIOLL UNE lE1K 2 UNE ipMNESS 3 CONTINUOUS INTERSTITIAL ❑4 EIFCRI.LINE 5 AUf01 'WMP ❑ 99 OTHER / D. LEAK DETECTION ❑ LIE oll ❑ TEm96 pO wffi IFAX IxrECTOR sNUToovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 REANUAL CONCILIATIONORV F-13 MAODNIIOZETORING ❑ 4 GAUGING AUTOMATIC TANK E:]5 MONITORING GROUND TER ❑ 6 TTEESTTINGTANK ❑ 7 MON CONTINUOUS INTERSTTIAL E:] 8 SIR ❑ 9 TANK LY MANUAL ❑10 MONTHLY TANK Qf 95 UNKNOWN THER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ^ `� 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM J DANCE 7 r (PRINTED S SIGNATURE) J(AI Imo// ✓V I l 11'` V 4�I�� 1 J LOCAL AGENCY USE ONLY THE STATEI,D.NUMBER IS CO P ED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION N FACILITY p TANK p STATE I.D.# m14 1161 d I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUSTSHOULD BE ACCOMPANIED BY AI PLOT PLLAAN. RLE THIS FTION-FORM ORM WITH THE CURRENT UNLESS A NS.THIS FORM LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6-95)