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e"tom. aaw�sx�^•r�:'e>Ri�`"a�iF+T'R'6=!L"�x?F" STATE OF CALIFORN' WATER RESOURCES CONTR BOARD .:. FORM 'B': UNDERGROUND STORAGE TANK PRCTGRAM TANK PERMIT APPLICATION INFORMATION y� TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. Z 1 NEWPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQ�FDH'IfpK 10 MARK ONLY ❑ r .TU/ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: d W CA) I R S {c ARM TANK-YES❑ NO Ca I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -.4 A. OWNERS TANK ID# B. MANUFACTURED BY: V CTI C. YEAR INSTALLED 19 6 D. TANK CAPACITY IN GALLONS: Q 47 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL n P,�ETROLEUM B. C. ❑ 1 UNLEADED ❑I 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT L�Q�/4 OIL [:] 1 RODUCT ❑ 4 GASAHOL ET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN Eff 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 2 HAZARDOUS SUBSTANCE STORED 8 C.A.S.# IN 0 C.A.S.W 2 D 7 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 LISLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS BIER. ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%MEIHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F—] 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4ynENOLICUNING LINING ❑5 GLASS LINING F-16 UNUNEO 95 UNKNOWN ,/r'/ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? F]YES ❑ NO 99 OTHER V D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT KI LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ PROTECTION 5 CATHODIC PROTECTION ❑ L 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IFUNDER ROUND,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 LINEDTRENCH 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^6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER /IY VI. NFORMATION 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m I I I I I I I IolaU CURRENT LOCAL AGENCY FACILRY ID# APPROVED BY NAM PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAT /PERMIT EXPIRATION DATE 2 CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEECODE RECEIPT# BY: \\W\tl FORM B(ss9-BB) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A WKRENT FORMA HAS BEEN FILED L4 DATA PROCESSING COPY