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STATE OF CALIFORNIA WATER RESOURCES CONTROL 90ARD FORM 'B': UNDE._ aROUND STORAGE TANK PROcrRAM - IRI TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ D RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /1-7� FACILITY/BITE NAME WHERE TANK IS INSTALLED: / ARM TANK-YES❑ NO •0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK 10 N i B. MANUFACTURED BY: W C. YEAR INSTALLED O. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. (,jt A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ❑ I UNLEADED ❑ 2 LEADED ❑ J DIESEL ❑O CHEMICAL PRODUCT A OIL ElI PRODUCTr ❑ A 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 A CAS.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A TYPE OF ❑ I DOUBLE WALLED ❑J SINGLE WALLED NTH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑J FIBERGLASS ❑ A STEEL CLAD W/FIBERGUSSREINFORCED PLASTIC R.TANK ❑ 5 COM•/IEh MATERIAL ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑8 10)%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYO LINING ❑J EPDXY LINING ❑ A PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE NTH 100%METHANOLi ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYERENEWRAP ❑ 2 TARORASPRALT ❑J VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC 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 TYPE A U I SUCTION A U 2 PRESSURE A U 0 GRAVItt A U YI NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 0 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U / 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 f l VISUAL CHECK P f 2 INVENTORY RECONCILIATION P f J VADOSE WELLS P f A ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS P S fi PRECISION TFSTING P 5 7 PRESSURE TESTING P f 91 NONE P f 95 UNKNOWN P f 99 OTHFR VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO7YR) 2 ESTIMATED OUANTITY OF J. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL! 0 YES ❑ ND THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRIMED A SIGNATURE) DATE 4 LOCAL AGENCY USE ONLY COUNTY E JURISDICTION N AGENCY E FACILITY ID N TANK ID X I I I % S CURRENT LOCAL AGENCY FACILITY 10• APPROVED BY NAM[ PHONE I WITH AREA CODE PERMIT NUMBER PERMR APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT/ BY: Y FORM B AT 29-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A,:,IRRENT FORMA HAS BEEN FILED / DATA PROCF$clbr nnn-