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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM w TANK / TANK PERMIT APPLICATION INFORMATION (a C MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT Zj-S_CHANGE OF INFORMATION ❑ 7PERMANENRY CL 1. ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE EaB TANKREMOVED LI FACILITY/SITE NAME WHERE TANK IS INSTALLED: FM—M7TANK-YES❑ NO FV - 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ��/ O ca A. OWNERS TANK IDN — B. MANUFACTURED BY: J C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: -SQ 11. TANKPONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1(,IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 1 OIL © 1 PRODUCT ❑ i DASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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 CA.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,{D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH E%TEIMIR EWER ❑ %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ /SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUITDN 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD WIRBERCLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMVAIM B 100%METHANOL COMPATIBLE FOP MATERIAL.. ❑ 9 BRONZE ❑ 10 GALVANIZED OR ❑%191KN011N ❑99 OTHER C INTERIOR F—] 1 R10BERUNHI ❑2/dMUNNG ❑3 EPDXY UNNG /PHENDUCUMNG LINING ❑5 GLASS l9LINC ❑6lIN1N® ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLTERIENEWRM ❑2 TAR OR ASPHALT ❑ 3 VINYLWR P /RIERG3=REINFORCED PLASTIC PROTECTION ❑5 CATHOOICPROTMI N ❑91 NOTE ❑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 A U 95 UNKNOWN A U %OTHER A U I STEELYWON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U N FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 { 1 VISUAL CHECK ► t 2 INVENTORY RECONCILIATION P f 9 VADDSE WELLS P t N ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS { 6 PRECISION TESTING P t 7 PRESSURE TESTING I t 91 NONE P t 95 UNKNOWN P f 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST IISO(MO/YR) 2. ESTIMATEDOUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING WOALLONt INERT MATFAIAL7 ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF W KNOWLEDGE.1S TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION 9 AGENCY 9 FACILITY ID 9 TANK ID N CURRENT LOCAL AGENCY FACILITY ID• ^ / .� APPROVED 9Y NAME PHONE A WITH AREl1 CODE PERMIT NUMBER J\,/fJ- J Fi/1 SMR APPROVAL DATE PERMIT EXPIRATION DATE -iz-f CHECKN PERMITAMOUNT SURCHARGE AMT. FEE CODE P--EIPTN BY: ` , 1oHM a(6-2969) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED DATA PROCESSING COPY