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Pt50URCE�3 CO STATE OF CALIFORNIA ." 1 STATE WATER RESOURCES CONTROL BOARD s g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a •Cit IIOR NIS COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY a i NEW PERMIT F7 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE ITEM El 2 INTERIM PERMIT F__] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK RE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 21tof-e, x-1411-7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A,OWNER'S TANK I.D.# 1 07-CC) B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 1172-7 -- D. TANK CAPACITY IN GALLONS: 1 D Wo il.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. v p 1 MOTOR VEHICLE FUEL 4 OIL B. C /� 1a REGULAR UNLEADED a 3 DIESEL 0 6 AVIATION GAS 2 PETROLEUM a 80 EMPTY 1 PRODUCT lb PREMIUM UNLEADED a 4 GASAHOL 7 METHANOL O 1c MIDGRADE UNLEADED 5 JET FUEL 8 M85 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 0 2 LEADED a 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 1 DOUBLE WALL F_� 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM LTJ 2 SINGLE WALL F-1 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL a 5 CONCRETE 0 6 POLYVINYL CHLORIDE F__j 7 ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E] 9 BRONZE a 10 GALVANIZED STEEL 0 95 UNKNOWN E] 99 OTHER C.INTERIOR F_� 1 RUBBER LINED 0 2 ALKYD LINING El 3 EPDXY LINING Q 4 PHENOLIC LINING LINING OR El 5 GLASS LINING 0 6 UNLINED ® 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR a 1 POLYETHYLENE WRAP F__] 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E::] 5 CATHODIC PROTECTION tZ 91 NONE E]95 UNKNOWN El 99 OTHER E.SPILL AND OVERFILL,etc. DROP CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES 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 AU02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION ACU)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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION W 1 MECHANICAL LINE LEAK trX,J IXSYI 2 LINE TIGHTNESS a 3 CONTINUOUS INTERSTITIAL 0 4 ELECTRONIC LINE 0 5 AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN 99 OTHER V.TANK LEAK DETECTION / 1 VISUAL CHECK E 2 RECONCILIATION MANUAL INVENTORY 3 VADOZE MONITORING � ' 4 GAUL AUTOMATTANK 5 MON GROND W TER 6 ANNUAL TANK 7 CONTINUOUS MONITORING INTERSTITIAL a 8 SIR a 9 TANK LY MANUAL 10 TO THLY TANK a 95 UNKNOWN 99 OTHER ESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES 0 NO F THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME 731 17 &j 2rl IA o g ] DATE (PRINTED6 SIGNATURE) /' �'1 � ��.,. Aef 4 t n Ll/k 14 LOCAL AGENCY USE ONLY THE STATE I.D.N R COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �IC�- TANK# 7 STATE I.D.4 z� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLY'--'14-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FC-"�-MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 1GROUND STORAGE TANK REGULATIONS FORM B (6-95)