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STATE OF CALIFORNIA WATER RESOURCES CONTROL POARD FORM 'B': / UNDERarIOUND STORAGE TANK PROGY.AM TANK t' TANK PERMIT APPLICATION INFORMATION ry COMPLETE A SEPARATE FORM WITH THE FOLLOWING JNFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCIOSE0 a• ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0 y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 G C -FA-RM TANK-YES❑ NO 1 •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID p - B. MANUFACTURED BY: W C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: - I r 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 ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 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 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,ED A.TYPE OF ❑ 1 DOIMLE WADED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑%UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENr ❑99 OTHER F-11 SIEEL/1RON ❑2 STAINLESSISTEEL F-1SEE 3 FIBERGLASS ❑4 R CLAD W/RBERGIASS REINFORCED PLASTIC B.TANK MATERIAL F-15 WNam ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑6109%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED ME ❑%UNKNOWN ❑%OTHER C.INTERIOR ❑ 1 RUBBER UNE ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH ICA METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHIENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPAOTECRON ❑91 NONE ❑%UNKNOWN ❑%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 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONSINERT MATERIAL? [DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY-/AGILITY ISD# APPROVED BY NAME PNONE#WITH AREA CODE V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE y CHECK• PERMIT AMOUNT SURCHARGEAMT. FEE COD! I RECEIPT# FORM B(a-n-M) THIS FORM MUST BE ACCOMPAMM BY A FACILITY/SITE APPLICATION, FORM 'A',UN RRENT FORMA' HAS SEEN FILED 1V^/11 DATA PROCESSING COPY