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STATE OF CALIFORNIA WATER RESOURCES CONTROL F")ARD ° FORM 'B': UNDERaROUND STORAGE TANK PROGF,AM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY K ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT '/�❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ?i 6 1''r F M TANK-YE$ NO •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 ?jZ A. OWNERS TANK ID N " B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q a all Ii II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. �Q A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL [–] T 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 HAZARDOUS SUBSTANCE STORED&C.A.S.9 C.A.S.3: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,E D A. TYPE OF ❑1 DOUBIEWALLM ❑3 SINGLE WALLED WIDI EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDAMCONTAINMENT 99 OTHER F-1i STEEUIRON ❑2 STMNLfS68TEEL F-13 FamiA55 ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM B 100%MEDMOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 AIM LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑IS UNNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLY(THLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN E] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI CABLE 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 / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL 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 STEELCLADW/FRP A U 8 109%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 S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P 3 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION A AGENCY k FACILITY ID 3 TANK ID 3 Ml = CURRENT LOCAL AGIMICTFACILITY IDP APPROVED BY NAME PHONE M WITH AREA CODE LUGS k5 I PERMIT NUMBER PER M IT APPA OVAL DATE PERMIT EXPIRATON DATE lc;wc-K—I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTI BY� FGRMB(a29-BB) THIS FORM MUST BEACCOMPA BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS : RRENT FORMA' HASBEENFRED DATA PROCESSING COPY