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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED N SITE ONE REM F-12 INTERIM PERMIT F-14 AMENDED PERMIT fi TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Aff 21104 e' I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A ❑ tb PREMIUM UNLEADED 4 GASAHOL ❑ ] METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY DV. 1 PRODUCT ❑ is MIOGRADE UTAEAOED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN f�❑�2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN"AD.BB.OWI D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A-S.A: 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 O 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 ;911 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO\yZ D.EXTERIOR ❑ I POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE F-1 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,#t0. SPILL CONTAINMENT I STALLED,YEAR) OVERFILL PREVENTN OUIPMENT 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 AQ 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AQ SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 ] 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 DETECTIONI MECHN KX ONE ceN 2 LINE IIGNiNESS 3 WNINUWS INIERSI 4 E.ECIRIXaC LINE 5 AUTOMATIC FUND 9 OTHER ❑ OETECTON ❑ TESTING ❑ MONTdING ❑ LEAK OETECTOP ❑ SHUIGOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECO CILIATION NUAL INVENTORY ❑ 3 MONNIITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑5 GROUND MONITORING 8 TESTIINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY EEKGAUGING ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED a 9GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 3FORM B (6.95) _ Q6 —�y /yam