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STATE OF CALIFORNIA WATER RESOURCES CONTRO *)ARD FORM B': UNDERC;ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 RMANENTLV CL K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE/� ' B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: QS o q_ ' {�1/I Q /i/ v/tT�ARM TANK-Y S❑ N 46 I. TANK DESCRIPTION OMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS STANK IDK B. MANUFACTURED BY W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A ,IS NOT MARKED,COMPLETE ITEM D. EV ED 3 DIESEL CLE A 3 CHEMICALPRODUCT ❑ 4 OIL PETROLEUM B 1 PRODUCT C ❑<GASAHOLD 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 8 CAS.K C.A.&#. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ABLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 9IE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ll�l STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC 8.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 FJIENOUG LINING LINING ❑5 GLASS UNING ❑6 UNLINED OWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES NO OTHER D. CORROSION ❑ 1 POLYETHLEIIEWRAP ❑2TAR OR ASPHALT W��95UNK:WOWN RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑99 OTHER IV. PIPING INFORMA N 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 U9 #KNOWN 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 NKNOWN 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 ALUMINUMCONCRETE A U 7 STEELCLADW/FAP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 VISUAL CHECK P S 21NVENTORY RECONCILIATION P f 3VAOOSEWELLS P ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P f 7 PRESSURE TESTI NG P S 91 NONE S UNKNOWN P S 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 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. I- APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION K AGENCY K FACILITY ID K TANK ID K El� = = 1 6f 4i r ovv CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE K WITH AREA CODE D I RMOI O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEE FILE DATA PROCESSING COPY