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STATE OF CALIFORNIA WATER RESOURCES CONTROL u0ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED Ts I O ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE / FACILITY/SITE NAME WHERE TANK IS INSTALLED: /� y ! W fav / ��.✓/✓� / F TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IU a +'7 B. MANUFACTURED BY: C. YEAR INSTALLED +j i' D. TANK CAPACITY IN GALLONS: II. 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 B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 5 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ I DOABLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E44uNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL VFIB S ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑8100%METHANOL COMPATIBLE FRP 9 BRONZE ❑10 GALVANIZED STEEL ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 P OLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED V1915 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IN%METHANOL? ❑YES NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT LWRAP ❑4 F18ERGLASS 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 5 UNKNOWN A U 99 OTHEfl 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 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FI RGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A yeyONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U!,0005 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P LECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 8 Y 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 INGALLONS INERT MATERIAL? ❑YES El NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK IO# CURRENT LOCAL AGE Y F C ,� , ^ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: `J F0RIA61e-29-ee) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM'A!,UNLESS A CURRENT FORMW HASBEENFILED DATA PROCESSING COPY