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0 i PtgOVXCts C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •CSL 10+1 M� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY JF 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON TE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � h I it ci t 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N Gfly"�3 rl B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) L� D. TANK CAPACITY IN GALLONS: wJ 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 9 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS Ell lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F-] 2 PETROLEUM ❑ 80 EMPTY K 1 PRODUCT n is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 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 IN 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 ig 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Ej 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING VC 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.EXTERIOR ® 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL tSPILL CONTAINMENT INSTALLED(YEAR) 6 OVERFILL['REVENTION EQUIPMENT INSTALLED(YEAR) +@C. DROP TUBE YES__V- NO STRIKER PLATE YES cf\ 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 W2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 STEEL W/COATING Ab 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 ilon-melDic, D. LEAK DETECTION W MECHANICAL LINE LEAK ❑2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION n❑ ANNUAL 1 VISUAL CHECK ❑ 2 RECONCILI TIIONMANUAL INVENTORY ❑ 3 MONITORING VADOZE4 GAUGNGAUTOMATIC TANK ❑5 MONTORINGGROUND WATER ❑ 6 TESTINGTANK �+ 7 CON TORNG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL F--] 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I 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 c 1-.1(!)Y10a DATE (PRINTED S SIGNATURE) SNL- `0 en G�� I� ♦�IZJ LOCAL AGENCY USE ONLY THE STATE I.DU&IFIIR C /POSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 60.Q5411 TANK# 005 STATE I.D:# m FFTI I Al 3 / 0 7 D 411311 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMITPLI -FORM A,UNLESS A CURRENT FORM A HAS BEEN FILM FQMfi MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTIEGROUND STORAGE TANK REGULATIONS FORM B (6-95) bb 410-4 in,