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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD FORM 'B': LINDER&OLIND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK G COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 'C ONE ITEM ❑ 2 INTERIM PERMIT F-]d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2(JS ARM TANK•YES NO 4!N- I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY •P A. OWNERS TANK ID R B. MANUFACTURED BY: —4 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q H. TANK CQlhTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. EVI MOTOR VEHICLE KIEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ d GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS 0 ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) I9,�jO D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.K C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA E995 UNKNOWN SYSTEM ❑ INGLEWAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER -- I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER -- - C. INTERIOR ❑ I RUBBERLINED ❑2 ALKYDUNING ❑3 EPDXY UMNG0y6NOUCUNING ! LINING ❑5 GLASS LINING ❑6 UNLINED 19 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETMENE WRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB VE 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 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A V95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U d FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADWIFRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U A5 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. I P 1 VISUAL CHECK P 011NVENTORV RECONCILIATION P 8 3VADOSE WELLS P S 4ELECTRONIC MONITOR P S SGROUNDWATER MONITORING WELLS o} 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(M07YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [-] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY R FACILITY ID B TANK ID a CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE F WITH AREA CODE G 7 �- PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCNANGE AMT. FEE CODE PFCEIPT X BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A LURRENT FORMA' HAS BEEN FILED+, 7� DATA PROCESSING COPY