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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Am. FORM 'B' UNDERGROUND STORAGE TANK PROGRAMTANK.TANK PERMIT APPLICATION INFORMATION z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH I C) 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE K MARK ONLY ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED ONE ITEM ❑2 INTERIM PERMIT ❑ ApM TANK-YES❑ NO w S`/K✓ } SZo p w FACILITY/SITE NAME WHERE TANK IS INSTALLED: W N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY00 B. MANUFACTURED BY: A. OWNERS TANK IDN G.YEAR INSTALLED Y„ D. TANK CAPACITY IN GALLONS: IL TANK NTENTS' IF(A.1),IS MARKED,COMPLETE ITEM C.11 (A.1),IS NOT MARKED, MYCETE ITEM D. B / C. 1 UNLEADED DED DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 P6T�%7LEUM I-{T,(P�DUCT ❑ LrJ`I II' L��"`" 4 GASAHOL 5 JET FUEL! n �6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑4 O L T METHANOL IgNOL 99/OTHBR`(OESCRI I I ITEM D,BELOW) ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A ❑ 1 BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALIID ❑4 SECONDARY CONTAINMENT 99 OTHER 1 ST EL ❑2 STA�4L STEEL: FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑fi POLYVINYLCHLORIDE '❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE I ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYOUNING ❑-�EPDXY LINING n eENOLIC LINING C.INTERIOR ❑5 GLASS UNING ❑6 UNLINED �L-Y95 UNKNOWN LININGF-1990THER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES MT10`" ❑ D.CORROSION ❑1 POLYETHLENE WRAP- ❑ 2 TAR OR ASPHALT ❑ 3 INYlWRAP ❑4 FIBERGLASS REINFORCED PLAST10,I PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LyX UNKNOWN ❑B9 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APP I A SYSTEM TYPE A IW 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U'91 NNE 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED , A U 2 DOUS SWALUED A U 3r I(BED TRENCH A U 1- ONE U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A 2 STAINLESSSTEEL A U 3"POLYVINYL ON IPV n A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U6 CONCRETE A U 7 STEEL CA NUFPIP Q A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A nu 95 UNKNOWN A U 99 OTHERT V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECON64Y,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4.*TRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURETESTING' P S 91 NONE. �'IF S UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE UST USED(MONFq 2.ESTIMATED QUA TjTtV OF 3.WAS TANK FILLED WITH SUBSTANOEREM IT/JN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJVIrPmTHE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# Q v 10 1 ( 101010171 CURRENT LOCAL AGENCY FACILITY IQN NS� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER UP`I! PERMIT APPROVAL DATE PERMIT EXPIRATION DATE � �Z.7�—fid' FjWZ7KO�RMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM a(6-29.66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS wRRENT FORM W' HAS BEEN FILED DATA PROCESSING COPY