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STATE OF CALIFORNIA _ WATER RESOURCES CONTROL L _ARD FORM B': UNDERGROUND STORAGE TANK PROGRAM :quo . TANK PERMIT APPLICATION INFORMATION Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK, to [FFACILITY/SIT;ENAME ARK ON ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLO ONE ITE ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W e E R,9 FARM TANK-YES NO ❑ IVO WHERE TANK IS INSTALLED: ! a "!� - _ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN 80 SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C. L] 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B' ❑3 CHEMICAL PRODUCT ❑d OIL 1 PRODUCT ❑ ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ ❑ ❑ [:]7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS 80 EMPTY 5 UNKNOWN 2 WASTE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 6 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ I DOUBLE WALLET ❑3 SINGLE WALLED WITH EXTERIELINER 5 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ ❑4 STEEL CLAD WIFIBERGLSS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑8 100%METHANOLOOMPATIBLEFRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑< M)LIC LINING C.INTERIOR 95 UNKNOWN LINING ❑5 GLASS LINING ❑6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 10A METHL? ❑YES ❑ NO ❑99 OTHER ANO D. CORROSION ❑ 1 POLYETHUENE WRAP ❑2 TAP OR ASPHALT 3 LWRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 U 3 GRAVITY A U 91 NONE AU 5 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCIAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL Ar,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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P 8 1 PRECISIONTESTING P S 7 PRESSURETESTING P S 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTTTV 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. APPUCANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# /% / . -;7 DG / CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE rc--xx I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY. 1f5- FORM B(s-29-9e) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS SEEN(FFIIILL,EDDI DATA PROCESSING COPY