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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD pmt =o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYLOBED O ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV irS DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 133 F au-1 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N IF B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) Al&Vo D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ED CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MKGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 89 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARK ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCT! MARK ONE ITEM ONLY IN BOXES A 8,AND C,AND ALL THAT APPLIES IN BOX ADE A. TYPE OF ❑ 1 DOUBLE ALL F73 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE W ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLA ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMIN ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE 70 GALVANIZED STEEL ❑ 95 UN OWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑/3EXYUNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 8 LINED ❑ KNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% ANOL7 YESO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTO. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIK TE YES NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U UNDER OUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESS E A 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DO WALL A U 3 NED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 AINLESS STEEL A U 3 NYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U YCONCRETE A U 7 STE /COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U/10 CATHODIC PROTECTION A U 95 NKNOWN A U 99 OTHER D. LEAK DETECTION 1 AIECKNaGL NNE IFAK 2 TaiH hES5 3 CONI&OWS IMAS11Ml 4 E OMC LME 5 MrUWATC NNP O ❑ OETECfOH ❑ STNO MOfRORaiG ❑ IfAK CTOR ❑ SNUn10WN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 C11JAL I VENTORY ❑ATION 3 VADOMONITORING ❑ 4 GAUGING C NK ❑ 5 MONITORING WATER ❑ 6 ANNUALTESTINTANK ❑ 7 OPNITI�UO INTRING ERSTITIAL ❑ 6 SIR ❑ 9 TANK GAUGING TESTING❑10 MONTHLY TAN ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATI (PERMANENT CLOSURE IN-PLACE) 1.ESTIMATEDDATE LAST USED(MO/DAV R) 2.ESTIMATED QUANTITY OF 3.WAS TANK LED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT M RIAL 7 THIS FORM HAS BEEN 96MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOML ,IS TRUE AND CORRECT TANK OWNER'S NAME DAIV IPRINTEDa SNNANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# QQ 7(y TANK# STATE 104I® p 9 (� PERMIT NUMBER PERMIT APPROVED BY/DATE 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 PLAN.-VILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNn`7GROUND STORAGE TANK REGULATIONS FORM a (6-95) J.w S�LZ� n `/