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STATE OF CALIFORNIA WATER RESOURCESCONTRf SOARD "'•�• a FORM 'B'- UNDL—KGROUND STORAGE TANK PROGRAM ' TANKv TANK PERMIT APPLICATION INFORMATION "o Y COMPLETE ASEPARATE FORM WITH THE FOLLOWING INF N FOR EACH TANK. - MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [-] 7 P ANENTLY CL ONE ITEM 1:12 INTERIM PERMIT [:]4 AMENDED PERMIT,7 ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: s�// S C /?�S/In ARM TANK-YES NO ❑ / / O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 7 4 37 L w A. OWNERS TANK IDR 77: B. MANUFACTURED BY: ClJ C. YEAR INSTALL D. TANK CAPACITY IN GALLONS: 15 11. TAN C TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARK ED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-1 IT 3 CHEMICAL PRODUCT ❑4 OIL RODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 0TH (DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A TYPE OF ❑ I OOUBIFWAUED ❑3 SINGLE WALLED WITH EXTERIOR LINER N SYSTEM ❑2 SINGLE WANED ❑q SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBE 55 ❑/STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 MINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IB GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR • ❑ I WWUNE ❑2 AMD UNING ❑3 EPDXY LINING §99 q LINING LINING ❑5 GLASS L1NNG ❑fi UNLINED lIS URN MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO0THER D.CORROSION ❑I POLYETHFNE WRAP ❑2 TARGRASPHALT ❑3 WRAP ❑ 4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑S CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE IX 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER pppV; LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR 11 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER IvVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY 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,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILI # TANK ID k �] L I 4 Y o CURRENT LOCAL AGENCY FACILITYIB"R ;SURCHARGE . APPROVED BYN PHONE/WITH AREA CODE PERMIT NUMBER RMIT APPROVAL DATE PERMIT EXPIRATION DATE �'. 12 7 1 CHECK# PERMITAMOUNT AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANh_,dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS.JRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY