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STATE OF CALIFORNI WATER RESOURCES CONTR( _ 30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK �/ TANK PERMIT APPLICATION INFORMATION ` V COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. —"" Z IG MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 /Y�/7GAA Av y�Op /c.1/1 F RM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY v A. OWNERS TANK ID ft 3 B. MANUFACTURED BY: 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LEA ICLE A ❑3 CHEMICALLe I MOTOR PRODUCT ❑4 OI�OLEUM B I PRODUCT C ❑4 GASAHOLD ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&O A.TYPE OF ❑ I UBLE WALLED ❑ 3SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARYCONTAINMENT ❑W OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING r7 4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GLASS LININGE]6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER Fi, 1111 D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE %UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A e CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS n P 8 6 PRECISION TESTING P 8 ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN MELONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# F7M = = oo lu 13 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE el-A,Ae1VZF 3® PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 7-1 s-Y CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: n/ FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A- HAS BEEN FILED DATA PROCESSING COPY