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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD • t' molt UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B J, C LETEASEPARATEFORMFOREACHTANKSYSTEM. 7524-44 MARK ONLY CJ O NEW PERMIT 3 RENEWAL PERMIT 7 PERMANENTLY CLOSkO OAITE b ONE REM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 161 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: T_5 qHELL I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.8 7524-44—RU-1 B. MANUFACTURED BY: RHEEM C. DATE INSTALLED(MOIDAYNEAR) 1977, D. T`NK CAPACITY IN GALLONS: 10 , 000 ILTANKCONTENTS IFA-i IS MARKED,COMPLETE ITEM C. —� A. ]® 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. yFyJ 1iUNLEADEO REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT yL�J� fO PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED CAS 0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C,AND ALL THAT APPLIES IN BOX O AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL _ILJ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmMyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING6 UNLINED 5L5.1 95 UNKNOWN oa OTHER LINING ❑ ❑ ULA ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVE RFILL PR EVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A0 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A& 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPAT18LE WIPRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 3 INTERSTITIAL D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK I-F—_1 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTMALMOMTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 APPLICANTS NAME DATE IPPoNTED 6 SIGN4N LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY p TANK STATE I.D.#4NVDI5 30 7 I I I I 18 A LE I I I 1 11 aQ I'D PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM 8 (7.91) THIS FORM MUST HE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS SEEN FILED. 2 �,/ FOR9m16 2