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STATE OF CALIFORNIf WATER RESOURCES CONTRO 'OARD FORM 'B': UNDERGROUND STORAGE TANK PRO LX6RAM p' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSE K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 100 FACILITY/SITE NAME WHERE TANK IS INBTALLED: Z- 3 &H21AZEKRM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i0 A. OWNERSTANKID# ' B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' OLIO W II. TANK CONTENTS IF(A.1),I$MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 A_ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED g?p3 DIESEL W ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑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&C.A.S.# C.A.S.#: All. TANK CON RUCTION MARK ONE ITEM ONLY IN BOXA,8,C,B D A TYPE OF E91 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 FBERGUSS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE Q;7 OMINUM ❑8100%METHANOL COMPATIBLE FRP ❑ MATERIAL 9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN ❑99 OTHER C INTERIOR F-11 R BBER UNm E]1 ALKYD LINING ❑3 EPDXY LINING ❑I ENOUC UNING UNING ❑ 5 GLASS UNING F-16 UNLINEDNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHIENEWRAP ❑2 TARORASPHALT ❑�LWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE rLrJ/95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A ?U1 SUCTION A U 2 PRESSURE A U 3 GRAVITYA 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE STEEL CUD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN ALU OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. - 021 / S 1 VISUAL CHECK S 2 INVENTOR/RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS [J� S 6 PRECISION TESTIN P 8 7 PRESSURETESTING P S 91 NONE- P S 95 UNKNOWN P 8 99 OTHER 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 GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EHI = = I ol a I/ lo 1v IS'l I (SOU CURRENT LOCAL AG CY FACILI 0; OVED BY NAME PHONE#WITH AREA CODE � L GNB PERMIT NUMBER IVITAPPROV A PERMIT EXPIRATION DATE I CHECKN PERMIT AMOUNT SURCNA GE AMT. FEE CODE L RECEIPTN BY: C FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED -� ,CESSING COPY