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STATE OF CALIFORN.) WATER RESOURCES CONTR,_,;BOARD FORM `B': ' . UNDERGROUND STORAGE TANK PROGRAM TANK. � TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z IO MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED 7 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT F-16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: n/ .j�/4? ZQ 6RM TANK-YES NO ❑ n] 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C> CD A. OWNERS TANK IDM B. MANUFACTURED BY; C. YEAR INSTALLED U _ D. TANK CAPACITY W GALLONS: CJ c) 11. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITE D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ffT2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ODUCT ❑ 4 GASAHOL ❑ 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 a C.A.S.0 C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 13OX A,B,C.a D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE !MATERIAL El POLYVINYLCHLORIDE ❑ 7 ALUMINUM 9 10094ME7HANOLCOMPATIBLE FRP .. � ' ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL E:].95 UNKNOWN ❑99 OTHER I C.INTERIOR ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHENOUCLINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN I ❑IS LINING MATERIAL COMPATIBLE WITH 10094 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1.POLYSHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASSREINFORCED PLASTIC PROTECTION. ❑5 CATHODIC PROTECTION ❑94 NONE ❑95 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 U 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEELYIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%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. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 ,91 NONE P B 95 UNKNOWN P 5-99-OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 72.ESTIMATEDOUANTITYOF 3. WAS TANK FILLED WITH STANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO ' GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION M AGENCY M FACILITY ID N TANK ID N I E IM40 O (_:2T<ql I CURRENT LOCAL AGENCY FAC%ITY ID# r-E APPROVED BY NAME PHONE i WITH AREA CODE PERMIT NUMBER /L-15' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE st'/�� CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE �ECEIPT f BY: FORM a(6-29.68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED .� nnrA Danrccmur_ rnnv - . - -