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STATE OF CALIFORNIf WATER RESOURCES CONTROI )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION - - -- -- - n-- L;IJMFLt I C A 5CPAHA It F'VHM WI IH IHCFVLLVWIN -INtVHMA I IVNL'VHCAL" IANK. 1-4� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ah,L ARM TANK - VES NO ❑ A. OWNERS TANK ID # B. MANUFACTURED BY: le C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A, ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL / ❑ 5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN B. F-11 PRODUCT ❑ 2 WASTE C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, HAZARDOUS SUBSTANCE STORED ENTER NAME OF S C.A.S. # ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT C.A.S. #: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D J A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN , SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIRE ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7MINIM ❑ B 10D%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING OLICUNING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED C. MATERIAL 95 UNKNOWN U 5 ALUMINUM A ❑ IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑YES NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 LWTIAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND, BOTH IFAPPLICABLE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH TANKID* A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AU 5 UNKNOWN A U 99 OTHER &-/q 8/' 7 B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE TPVC) A U 4 RBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLAD W/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A �LI /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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE PIS 5 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 TANKID* SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO APPROVED BY NAME GALLONS PERMIT NUMBER THIS F( HM HAS BEEN DUMPLE ILL) UNULH PLAI OF PEHJUHY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CI APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY # JURISDICTION # AGENCY # FACILITY/ ID # TANKID* CURRENT LOCAL AG Y FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODEERM PERMIT NUMBER PERMIT APPROVAL DATE PXPIRATION DATE &-/q 8/' 7 CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPrN BY: � .�/ FORM 6 (6-29-m) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM'A' HAS BEEN FILED Z 10