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I. I ANK UhJGKIF I IUN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN V A. OWNERS TANK I. D. N / B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) , 93p 0. TANK CAPACITY IN GALLONS: 9 TAalvrnMkonrte,................,.,....,-rr,-,.�.... �.�a...� A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. ❑ leUNL ULAR DIESELGASAH B E::]6 AVIATIONGAS STATE OF CALIFORNIASTATE ❑ 80 EMPTY LrYJ/ 1 PRODUCT ib PREMIUM WATER RESOURCES CONTROL BOARDUNDERGROUND I --]]METHANOL ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE a UNLEADE❑ FUEL ❑ 5 dETHER MATERIALAND 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE A SEPARATE FORM FORE H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOS TE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 7 %l 1 �/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: fn -% -'3 a P • HJ .Q" ❑ 4 PHENOLIC LINING I. I ANK UhJGKIF I IUN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN V A. OWNERS TANK I. D. N / B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) , 93p 0. TANK CAPACITY IN GALLONS: 9 TAalvrnMkonrte,................,.,....,-rr,-,.�.... �.�a...� A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. ❑ leUNL ULAR DIESELGASAH B E::]6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY LrYJ/ 1 PRODUCT ib PREMIUM 4 L I --]]METHANOL ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK 3 LINED TRENCH UNLEADE❑ FUEL ❑ 5 dETHER MATERIALAND 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ W OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 9 BRONZE C. A. S. s: ❑ 95 UNKNOWN III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF II DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ,❑-., T;'2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIALAND MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING UNLINED F-195 UNKNOWN ❑ 99 OTHER LINING A U 99 OTHER D. LEAK DETECTION ❑ 1 IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑' 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR)T� � OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIALAND �'��U//��,,1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZEDSTEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTINGIAL ❑ 3 ❑ OTHER MONITORING I. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING x91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST SE}(MOIDAY/VR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH JY .�' — I y/ SUBSTANCE REMAINING GALLONS INERTMATERIALT YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW-rkht,t Jo COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED �., ... -7- Al-