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---� STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B i Jl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. Ja-.,o_ S Z I b:;%3 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: k 0,57 2 33 O 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.1 T14, 1�5 7S 3 B. MANUFACTURED BY: C. DATE INSTALLED(MG'DAY/YEAR) U / D. TANK CAPACITY IN GALLONS: II:TANK CONTENTS IF A-1 IS MARKED,COMPLETE REM C. A ❑ / MOTOR VEHICLE FUEL ❑ 4 OIL B. C. le REGULAR UNLEADED n3 DIESEL ❑ 6 AVIATION GAS O NLJ 1E PREMUM UNLEADED I4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ a0 EMPTY ❑ 1 PRODUCT ❑ 1c MIDGR/DE UNLEADED5 JETFUEL ❑ 9 MBS ❑ 3 CHFAIICALPRODUCT BS UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTNEA(DESCRIBENREMD.BELOM D. IF(Al)ISNOT MARKED. ENTER NAME OFSUBSTANCE STORED ZI-Vo CJL / C.A.S.4: III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E A.TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ S INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN - SYSTEM lo�2 SINGLE WALL ❑ 4 SINGLE WALL M A VAULT ❑ 99 OTHER E. TANK (E�J,1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL- ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE W/FRP (PrM-YTmW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 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 101% METHANOL? YES_ NO_ - D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F--j 2 COATING D 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION [-]UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION E23-81 NONE ❑ [-] SPILL CONTAINMENT INSTAI I Fn(YEARN - - OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,MC. DROP TUBE YES_ NO Q 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& 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U W OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U W OTHER G MATERIAL AND A® 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE I CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER O. LEAK DETECTION 1 w<�rx ' 0'= rss ❑a NrD6I^ut Q 4 O s Aownc auv O 99 orHER ' �— V.TANK LEAK DETECTION ❑ ? NSUPL CHECK ❑ 2 MANUALIUI VENTATION RY ❑31AONRORING ❑ 4 GAUGING C TANK ❑5 GROUND MONITORING ❑B TESTING RECONC❑ T MONITORING INTERSTITIAL ❑ 9 SIR ❑S TANK� SY MANUAL O 10 TESTING LY TANK �Iy'g5 UNKNOWN ❑99 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE WI-ACE) v 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTRY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING U. GALLONS INERT MATERIAL?- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME .HCNATUREI, .lam/ %�,✓ �G `,, , _ _ - _ _ 1.� -2-� 1 LOCAL AGENCY USE ONLY TH STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION f FACIUTYO TA� STATE-I.D# PERMIT NUMBER'- - PERMIT APPROVED BWDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA RAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILETHIS FOWL WTTHTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FDRMB (695)