SITE INFORMATION AND CORRESPONDENCE

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�sw"`ea STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD +mom, •,._ e g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE STEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: E. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D. B. MANS UFACTURED BY: v C. HATE INSTALLED(MOIDAYNEAR) 61,11.�� O. TANK CAPACITY IN GALLONS: ] [I.TANK CONTENTS IFA-i IS MARKED,COMPLETE ITEM C. -c-, L❑ A ❑ 1 MOTOR VEHICLE FUEL i r r OIL B C. Li to REGULAR UN-MED ❑ 3 DIESEL ❑ 5 AVIATION GAS 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ Tb PREMIUM UK.EADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MMGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE ❑ 2 LEADED 99 OTHER MESCIBE IN ITEM 0.8EIXM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED rjGyl.3 y�� p/ C.A.S.R 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 ❑ I DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR I NER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER $. TANK C��}\1 13ARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL U 5'GONCRETE ❑ 6 POLYVINYL,CHLORIDE ❑ 7 (ALUMINUM 8 100% METHANOL. COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ TO GALVANIZED STEEL E] 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ B UNLINED S.-95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR i POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION C::] 91 NONE Noy UNKNOWN ❑ 99 OTHER E SPILL AND OVEAF)LL,EtC. SPILL CONTAINMENT INSTALLED(YEAR) LL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES I NO DISPENSER CONTAINMENT YES NO 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 rl]GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AV I SINGLE WALL A U 2- DOUBLE WALL A U 3 1LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 B CONCRETE A U 7 STEEL W/COATING A U S 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 AECHROM UNE LEW 2 UNE Tlt*UW—q3 3 COffrMa S NnU145 M 4 EEECIAOMC UNE 5 AUrOVAT10 PUMP D. LEAK DETECTION ❑ �� [:] TESnNa ❑ womgcR G I ❑ LW OETECTOR ❑ SWJTMM Q 99 OTHER V.TANK LEAK DETECTION ❑ 1, VISUAL CHECK ❑ 2 MA UAL RECONCILIATION ORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MON MONITOUND RING ANNUALTANK ❑8 TESTING ❑ 7 MONITORING INTERSTMAL ❑ 8 SIR ❑ 9 TAWEEKLY EK L M NUAJ❑ 10 TES�GY TANK 5 UNKNOWN a 99 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACEI 1.ESTIMATED DATE LAST USED( IY 2.ESTIMATED QUANTITY OF y�I 3.WAS TANK FILLED WITH YESNO �• SUBSTANCE REMAINING i:/ GALLONS I INERT MATERIAL? ❑ a THIS FORM NAS BEEN COMPUTED UNDER PENALTY OF PERJURY,AND ik'O THE&EST OF MY KNOWLEDGE 1S TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE( -. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# G� STATE I.Dl PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIFIATIQN DATE 7 e T � THIS FORM FAUST BE ACCOMPANIED 9Y A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETER FOR INSTALLATIONS.THIS FORM.: SHOULD BE ACCOMPANIED BY A PLOT PJWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH ERGROUND STORAGE TANK REGULATIONS .FORMB (6495) _ r