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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z IU MARK ONLY ❑ 1 NEW PERMIT r-] 3 RENEWALPERMIT LiKICHANGE OF INFORMATION [:17 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT [:]4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑R TANK REMOVED � J N � FACILITY/SITE NAME WHERE TANK IS INSTALLED: I S s r L S ARM TANK-YES❑ NO,� 41111- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O C=I A. OWNERS TANK ID# B. MANUFACTUREDBY: C. YEAH INSTALLED 1 G(c, I D. TANK CAPACITY IN GALLONS: II. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED R. 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL i PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EM ❑95 UNKNOWN , 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE INITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER N E OF HAZARDOUS SUBSTANCE STORED&C. .S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D / A.TYPE OF ❑ 1 DOU EWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEP ❑ 95 UNKNOWN SYSTEM SINGLEWAL ED ❑4 SECONDARY CONTAINMENT ❑ W OTHER MI'STEBUIRON ❑2 STAINLESS STEEL FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDEY7 ALUMINUM r7B 100%METHANOL COMPATIBLE RRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 AL NTNG ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING UNLINED [-] 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑ NO �99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2_-OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASRC �j f PROTECTION ❑5 CATHODIC PROTECTION Ef 91 NONE ❑95 UNKNOWN ❑ 99 OTHER fLyL IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U i SUCTION AM 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 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 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A( 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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 1 ELECTRONIC MONITOR P B 5 GROUNDWATER MONITORING WELLS P S)6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE A d° ORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 U> I ol A I1 CURRENT LOCAL AOENCYF �ID/� APPROVE�YN ME� PHONE WITH AREA CODE PERMIT NUMBER G PERMIT APPROVAL DAT! J`MIT EXP ON DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: /I FORM 3(6 29-88) THIS FORM MUST BE ACCOMPANIED b1 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY