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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM '.. TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAN .� MARK ONLY^ ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT C . CHANGE OF INFORMATION 7 PERMANENTL(YQWSEO TANK ONE ITEM I ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED/e, �U3 d ,P MM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IC A. OWNERS TANK ID#Z II B. MANUFACTURED BY:n46 C. YEAR INSTALLED (✓N D. TANK CAPACITY IN GALLONS: CA1 II. TANK C TE S IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA) A. Rl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. p C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL pgODUCT ❑ 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 O HAZARDOUS SUBSTANCE STORED&CAS.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A o A TYPE OF .{ F-11 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM �T ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1ST RATION ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC &TANK MATERI ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE [—] 7 ❑8100%METHANOL COMPATIBLE RTP ❑9 BRONZE ❑ 10 GALVANIZED STEEL %UNKNOWN ❑99 OTHER I(p ❑1 RUBBER LINED ❑ 2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHE UNING C.LININ O LINING ❑5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL �� YES ❑ NO ❑ 99 OTHER D. CORROSI 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 V WRAP ❑4 FIBERGLASS REINFORCED PUS TIC 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 TYPEA U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER L/ A B. CONSTRUCTION A U / SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH AU 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIA ; A U 5ALUMINUM A�fi CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5 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 ^ P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING 1 NONE P 8 95 UNKNOWN P S 99 OTHER 11 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . ESTIMATED DATE LAST USED(MO7YR) 2.ESTIMATED QUANTITY OFA/ WAS TANK FILLED WITH 1 n SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO /, THIS FORM HAS&EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE OPAL AGENCY USE ONLY 7�)COUNTY# JURISDICTION# AGENCY# G�7 FACILITY ID 8 'J 7 TANK ID# 42 ENT LOCAL AGENCY FACILITY ID# VED BY NAME ONE#WITH AREA CODE 2 L RMIT NUMBER ITAPPROV TE PERMIT IRATION DATE D CHECK# PERMIT AMOUNT SURCMIDIGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEUV A FACILITYYSITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY