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STATE OF CALIFORNIP WATER RESOURCES CONTRC 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION I ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. 1 - z 10 MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT C5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 s , ,E71_ 0,e 057- ARM TANK-YES❑ NO [gW V I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK ID# B. MANUFACTURED BY: ,4-7 1f W C. YEAR INSTALLED C D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1) MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL PETROLEUMB. C. ❑ 1 UNLEADED [:]2 LEADED ❑ 3 DIESEL EMICAL ❑3 CHPRODUCT 4 OIL i PRODUCT ❑ 4 GASAHOLVEIT FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY [:]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOLTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W D III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE I�I#WMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL Luj]7�1 ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2ALIPYD LINING ❑3 EPDXY LINING LINING UNING INING NUMED MKNOWN LINING SLIINIINNGLMATERIAL COMPATIBLE WITH Wt HI100%MEHANOL? ❑YES [-] NO OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALTIWL WRAP ❑ 4 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 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 ALUMINUMA CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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. �A/ P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B S GROUND WATER MONITORING WELLS � P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE j 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 7� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO Lyp1 \ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. /Pf APPLICANT'S NAME(PRINTED B SIGNATURE) DATE j LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# a o l 0 9 b CURRENT LOCAL AGENCY FACILRY ID# G APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE -.RECEIPT# BY FORM B(5-29-SS) THIS FORM MUST BE ACCOMVANIEDIBY,A FACILITY/SITE APPLICATION, FORM A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY