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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD a FORM B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATIONTANK. ✓' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE e TANK REMOVED ❑ W FARM TANK-YES V NO IVO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK ID# ��f Al a5 ic 8. MANUFACTURED BY: f' �- D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 14 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C A. F-11 MOTOR VEHICLE FUEL [-] 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ ❑3 CHEMICAL PRODUCT E]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 / //�__ C.A.S.W HAZARDOUS SUBSTANCE STORED 8 C.A.S.# �/L III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑I DOUB.EWALLED ❑3 SINGLEWALLm WITHEXTERIORUNER UNKNOWN SYSTEM ❑2 SINGLE WALED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 SIERARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERS ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 PHEN WING C. INTERIOR 5 GLASS UNING6 UNLINED UNKNOWN LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 990THER D. CORROSION ❑1 POLYEDIIENEWRAP ❑2TAR OR ASPHALT ❑ 3 VI P ❑4 FlBERGLASS flEINfORCED PLASTIC PROTECTION �5 CATHODIC PROTECTION 91 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 NONECA U 95 U U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONC A U 95 UNKNO 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 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL UNKNOW 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 S 1VISUAL CHECK P S 21NVENTORYRECONCIUATION P S 3VADOSE WELLS ONITOR P B S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P95 UN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTTTY 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# I I I wi A I o6 1 10 10va CURRENT LOCAL AGENCYY F � ptl�/ APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER LL PERMIT APPROVAL DATE PERMIT EXPIRATION DATE >,IL' CNECK tl PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: / FORM B(6-29-813) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY