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0 STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °'Leel COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ON S TE ONE REM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 'J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ihlord ,)IOrG 1-7 CPA 7 l I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 1-74,4-7 —01 B. MANUFACTURED BY: TOtaj 6or tarY1MEYv� C. DATE INSTALLED(MO/DAY/YEAR) lqq b D. TANK CAPACITY IN GALLONS: 'D 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. �. 1 MOTOR VEHICLE FUEL 1❑ 4 OIL B. C. 1G 1a REGULAR UNLEADED ❑ 3 DIESEL E] 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® i PRODUCT ❑ PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMD.BELOM D. IF(A1)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 A. TYPE OF IL_AJ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �7❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK U 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 W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 9K1 6 UNLINED ❑ Y95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001% METHANOL? YES G NO— D.EXTERIOR IC 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE VES� NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES-b�— NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 WI COATING A U 8 100% METHANOL COMPATIBLE W/FIR,P PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A©99 OTHER 1 IBC7� rY7Y!—TACIS�I D. LEAK DETECTION I WCW IM UNE OF K ❑2 LINE TIGWN n I�✓�CWINUWS IMERSTIINL O 4 EMMONIC UNE 5 AUf01MTIL POMP ❑ 99 OTHER OETECLOR TESTING LJ MONITORING LEAK GEIECTOR SHOiDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILATIONANUAL INVENTORY ❑ 3 MONITORING 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND MONTORINGTER ❑ 6 ANNUA TES INGTANK ® 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TW GAUGINGAL ❑ 10 MESn HGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MC/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WASTANK FILLED WITH YES E—] NO0 SUBSTANCE REMAINING GALLONS IN MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME Zai-la _2YUI^D DATE (PRINTED&SIGNATURE) n t- -for o4wwr LOCAL AGENCY USE ONLY THE STATE I.D.NUM R IS COMPOSED OF THE FOUR NUMBERS BELOW v COUNTY# JURISDICTION# FACILITY# D 00,5D& TANK# D STATE 04 m a 3 1 '{ o� d1,7 19 114 I:ql PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM (6-95) L6