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STATE OF CALIFORNIA .� STATE WATER RESOURCES CONTROL BOARD pym� .. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOS I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK RE w{ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1313 E. C_AAAZ&,& Cl I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: A C. DATE INSTALLED(MOA7AYNEAR) 'WdD. TANK CAPACITY IN GALLONS: / II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEPDED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY I��py1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL X ❑ 1C MIDGRADE UNLEADEDnI� 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED u 99 OTHER(DESCRIBE N REM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. III. TANK CONSTRUC N MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 BLE WALL [j3 SINGLE WALL WITH EXTERIOR LINER INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM [-12 SI WALL ❑ 4 SINGLE WALL IN A VAULT Jz 99 OTHER B. TANK ❑ 1 BARE L ❑ 2 STAINLESS STEEL ❑ 3 FIB/sS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALU ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNavyTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 'ED2 ALKYD LINING ❑ 3 XY LINING E] 4 PHENOLIC LINING LINING OR F-15 GLASS LINING ❑ 6 UNLINED ❑ UNKNOWN F-199 OTHER COATING IS LINING MATERIAL COMPATI WITH 100% METHANOL? Y _ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 81 NONE F-]95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,6L6. SPILL CONTAINMENT INSTAL (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES NO IKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFABOVEG NDO U IF UNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 ` SURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 89 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 LE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTEEL A U STAI SS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A 6 CONCR A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL U 10 CATHOD PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IECNN UNE IFAIc LINE mrtxess 3 xuous WTBGTnuL 4 ELECIRWIC UNE 5 A 0"M NW❑ ODTLTOR TESTING M TGIIING Um GETECTGR SHJiW1YN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2ANNUAL ECONCILIATIONORY INVENT ❑ 3 MONIITORING VAOZE ❑ 4 GAUGING C TANK ❑ 5 GMONITORINGAUTOMATIROUND �R ❑ 8 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ SIR ❑ 9 TANK GAUGINGAL ❑10 T SNG CONTINUOUS TIY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMA N(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/D NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 01`3 COUNTY# JURISDICTION# FACILITY# 00-4 W G . TANK# f� STATE I.D.# XT = A -311Rq a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U" -9GROUND STORAGE TANK REGULATIONS FORM (6-95) A) �o s I a. - 9, 7, ? 9 ,I