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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT X 5 CHANGE OF INFORMATION ❑ T PERMANENTLY C ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED /fl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 11313 F_ C/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MOA7AV/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS F-1 2 PETROLEUM BO EMPTY 219"t PRODUCT lb PREMIUM UNLEADED 4 GASAHOL ❑ T METHANOL ❑ ❑ ❑ 1c MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M65 MI ❑ 3 CHECALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 9THER(DESCRIBE N ITEM D.BELOW] D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. .R III. TANK C NSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX GANG E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ INTERNAL BLADDER SYSTEM ❑ 95 UNNNOVM SYSTEM ❑ 2 GLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK ❑ 1 BARE L ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ T ALUMINU ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary TwIQ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UN OWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING XYES— OXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING UNLINED NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL4NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATIN ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 81 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLD. SPILL CONTAINMENT INSTALLED(YEA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKE TE VES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE OUNDOR U IF UNDER UND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION X U 2 PRESSURE A U GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UhRZ 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 POLWI CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINU A U B CONCRETE A U 7 STEEL W/CO G A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALV ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNO A U 89 OTHER D. LEAK DETECTION 1 w UNE Ir:AN 2 INE mRNEss 3 w tXUS IxrERSnnAL 4 81C C UNE s AMMArK nw ❑ ❑ pErE ❑ TESIN9 ❑ LX1Mrd ❑ ¢adt DETECTOR SHViDOWN 99 oTHFA V.TANK LEAK DETECTIO ❑ 1 VISUAL CHECK ❑ 2 ❑ MANUALINVENTORY E—] 3 VADZE ❑ 4 AUTOMATIC TANK ❑ 5 ODWATER 6 ANTANK RECONCILIATION LNG GGT ❑ NUAL TMTER �� ❑ SIR 0 TAEKL10 ❑ U OTHER MONITORING N ❑ TA= M gs VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MODAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 ES [:] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE,)J0 CORRECT ITXKTANK OWNER'S NAME DATE D86IERS NE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY R OD371p TANK R Q 7 STATE LD:# 3 1 0 z d D 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 ��TP ��SSFORM WITH THE LOCAL AGENCY IMPLEMENTING THE US""RGROUNDSTORAGE TANK REGULATIONS FORMS (6fctl