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«nom F ,y 6 i_ '-01- %-,PAL -,;r•I:__.n; 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 TANK. MARK ONLY, ❑ I NEW PERMIT 7 RENEWAL PERMIT ❑ 5 CHANGE Of INFORMATION � 7 PERMANENTLY CLO( TANK ONE ITEM V/ 0 2 INTERIM PERMIT /AM!NOEB PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY LL /SITE NAME WHERE TANK IS INSTAED: DSO P-CQC C ARM TANK-YES❑ NO ❑ J I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC/FY to A. OWNERS TANK IDM -- B. MANUFACTURED BY C. YEAR INSTALLED D TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. co A ❑ t MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8 O C I UM EARED 1-1 2 LEADED ❑ 7 DIESEL N ❑ 7 CHEMICAL PRODUCT Olt 1 PRODUCT ❑ GA$AHgL ❑ S JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE // ❑ / METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CAS.M 12 _ CAS . �3 .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A e,C,i D [WATER F ❑ I DOUBTEWAUED ❑]SINGLE WALLED WITH F%TEROR LINEA 95 UNKNOWN I/ ❑2 y7NpE WNL® ❑A SEODWA TW WMANMEIIT ❑99 OTHER r I STEEL/IRON ❑2 STNNESSSTEEL ❑ 7 FIBERGLASS L STEEL CLAD WMBEWAASS FE FLFORCED MSfIC �J ❑ 5 LUIICFEfE ❑6 POLYYNYLOLOKE ❑ 7 ALUANIM ❑6 IW%METHAKOLCDMPA7BLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEfl ❑ 95 IJNKIQKII ❑99 OTHER G INTERIOR ❑ I NABEP LIMO ❑2 NXYD LINING ❑ 7 EPOAY UANG ❑1 PHENOLIC UINB UMI //_ (L ❑5 ASSUING ❑6I1N91® El 95 tmmN �J ❑ S INN'WTSL4 OCYPATW MM 100%1E1IW101oYES ❑ NO ❑99 OTHER D.CORK I POLATNBEWRAP ❑2 TNI OR ASRNLT ❑ J VIRAL WRAP ❑A FIBERGLASSIENIOILTD MASBC PROTECT" ❑S CATHOOILPROTECTION ❑91 1101E ❑95 U.OPOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUPED, U IF UN?ERGROUNO.BOTH IF APPLICABLE A SYSTEM TYPE A U I STICTION A U 2 PRESSURE A U 9 GRAVITY A U 99 OTHER IL COMMA U 1 S►N3LE WADED A U 2 DOUBLEWALLED A U O UNED TRENCH A U ob IRN/K)WN A U 99 OTHER A U 1 STFEL/FIUI A U 2 STAPILESSSTEEL A U 7 POLYVRIYL CHLORIDE(PVCI A U . FlBEROlA59 ROE G MATERIAL A U 6 ALIIMINIM A U G CONCRETE A U 7 STEELCLADW/FW A U 6 IPXM METHANOL COMPATIBLE FRP A U 9 GALVANIZW STEEL A U 96 lRKN01VN A U B9 OTHER V. LEAK DETECTION SYSTEM CIRCLE p FOR PRIMARY OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I VISUAL CHECK P i t INVENTORY RECONCILIATION P i J VADOSE WELLS P t . ELECTRONIC MONITOR p F 5 GROUND WATER MONROMNG WE113 6 PRECISION TESTING P i 7 PRESSURE TESTING P F 91 NONE p i e6 UKNOWN p % " OTHER BVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 IMATED DATE LAST USED(MO/YR) STIMATED OUANTIT f OF AS TANK FILLED WITH L{ l ANCF REMAINING IN GAILONF RT MATERIAL'! E]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APKJCMn RAW M*NTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY JURWICT1OONN8 -AGENCY• II FACRfTYID• Z TANK ID r , ✓ l i" LOQAL ABiNCY FACLfWT ID F KUws/�'/S_� /7 MIOIM.WITN M[A COD! PMIW761UWf11 AL CA PaL66rr 1DDIIIATIDN BA" 'c' i