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0 0 ouRcgs STATE OF CALIFORNIA .p"f ...... °01 STATE WATER RESOURCES CONTROL BOARD ; g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B ; s . •��I.FOM�'� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'JA 45 M /A/1 M i W,Ie-E7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 33 pb-S B. MANUFACTURED BY: Z"doP, C. DATE INSTALLED(MO/DAY/YEAR) ve-c �- D. TANK CAPACITY IN GALLONS: f5,C)O0 15'1000 SPLIT II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, 1?51 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 'ps: 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 21 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �<4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etC. SPILL CONTAINMEN INSTALLED(YEAR) OVERFILL REVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES X 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 A 0 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 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 0 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION i MECHANICAL LINE LEAK 2 LINE TIGHTNESS I\71'3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING L�l� MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION `❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY ❑ 3 VADOZE MONITORING 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TESTING F-1 ANNUAL TANK 6 TESTING "-' 7 MONITOR CONTINUOUS E] 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MO TINLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER 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 YES /�I SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE) ' /J T/,o1 LOCAL AGENCY USE L H TE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#0,/)394/7 TANK#oe& STATE I.D.4 IA1311 1 l PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI$FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1011 FORM B (6-95) 3,30-6116 49w-