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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD % UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > 1 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE MARK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED•J ' C DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ! N y 1 -'A4" -Qv ❑ 3 FIBERGLASS I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. O / B. MANUFACTURED BY: v' �O✓A C. DATE INSTALLED (MO/DAY/YEAR) flit nO �h D. TANK CAPACITY IN GALLONS: M TAAIVP^K"CA Q — --- F-] c ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT 4' OIL ❑ 80 EMPTY ❑ 95 UNKNOWN B. O 1 PRODUCT ❑ 2 WASTE C. ❑ 10 REGULAR ❑ 16IDED UNLEADED ❑ 2 LEADED O 4 DIESEL L ❑ 6 AVIATION GAS ❑ 5 JET FUEL ❑ 7 METHANOL [ftlig OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED M 0 Vo rQ ( C. A. S. # : III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C, AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 $INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL EHI 95 UNKNOWN ❑ 99 OTHER D. ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING F-1� 6 UNLINED 5 UNKNOWN ❑ 99 OTHER LINING 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 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGROUND. BOTH IFAPPIIDARIF A. SYSTEM TYPE kvSUCTION XW1 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A©95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U / BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL Wt COATING A U 8 100% METHANOL COMPATIBLE W/FRP A19)95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E?< AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TES TING ❑ 3 MONITORING ❑ 99 OTHER /. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ T INTERSTITIAL MONITORING ❑ 91 NONE Q 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MO/DAYIYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES [-] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # lJ73,¢L I y STATE LDAF-sFq� = I 11(, 1,51 t1l al6 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A,,UNLURRENT FORM A HAS BEEN FILED. _ FOROMB-115 7 I \� �/