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STATE OF CALIFORNV WATER RESOURCES CONTRO' -IOARD FORM 'B': UNDERGROUND STORAGE TANK PRO;3*IAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� 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 ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: %Q ARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i A. OWNERS TANK ID# UL` B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: �J W 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. CI A. G . MOTOR VEHICLE FUEL ❑ 2 P ROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL N F-13 CHEMICAL PRODUCT OIL r PRODUCT ❑4 GASAHOL ❑ 5 JET EL ❑6 AVIATION GAS F] 5 HAZARDOUS ❑80 EMPTY [-] AST 95 UNKNOWN J E ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# 9��i �� C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A TYPE OF DOABLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGUSS E21ML CLAD W/RBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81 OD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UA(NOIVII ❑99 OTHER ❑ 1 RIBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑/ LINING C. INTERIOR ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3VINYLWRAP ❑4 FIBERGLASS REINFORCEDPIASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 10�95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A 09 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A099OTHER DIQr"Z.T I0D +pgyvl .. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. y )IP S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELL P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER Y VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t. ESTIMATED DATE L63T 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � = = O U 6- 1!5-15T I DO CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN 8Y: FORM B(34-88) THIS FORM MUST BE ACCOMPANIE00A FACILITY/SITE APPLICATION, FORM `A',UNLESS A r RRENT FORMA' HAS BEEN FILED