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STATE OF CALIFORNIA_ WATER RESOURCES CONTROL )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 'rA wilt TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ERIS CHANGE OF INFORMATION ❑ 7 PERMANENTLY /C K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED/PERMIT ❑/ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE/ / FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z 3 6 BGo SSoAl RdAQ�; BM TANK YES 9?1NO ❑ C 76 J ANK UCSL.MIr I IUN COMPLETE ALL ITEMS - IF MNKNV WN — Su armv.ri A. OWNERS TANK ID # j I B. MANUFACTURED BY: E:]1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Ukl II. TANK CONTENTS m u u Be uARMen muni PTE ITEM r IF IA 11 IR NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC. E:]1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY95 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 CA.S. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U ❑ 1 STEBURON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B MR METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F -1I RUBBER UNED ID2 ALKYD LINING ❑ 3 EPDXY LINING 4 P_HRMC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ fi UNLINED A U 91 NONE UNKNOWN C. MATERIAL ❑ ISUNING MATERIAL COMPATIBLE WITH 109%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑ 2 TAR OR ASPHALT❑ 3 LWRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN 96" ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 2. ESTIMATED OUANTITY OFOALLONB 3. WAS TANK FILLED WITH FACILITY IDM A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A P95 UNKNOWN A U 99 OTHER PERMIT NUMBER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 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 A U 7 STEELCLADW/FRP A U S 10 METHANOL COMPATIBLE FRP A U 9 GALVANIZEO STEEL U%CONCRETE Af 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 5 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P jL 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 9 /8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OUANTITY OFOALLONB 3. WAS TANK FILLED WITH FACILITY IDM SUBSTANCE REMAINING IN INERT MATERIAL? YES [:]NO O 1 �63 THIS A RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND C( APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY# JURISDICTION# AGENCY# FACILITY IDM TANKID# O 1 �63 10 10 10 CURRENT LOCAL AGENC ACI_ ////II((,/ (('//TT�� 'J"J{ 7/ APPROVED BY NAME PHONE# WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# FORM B (6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY Z 10 CA.) N Q u0u I'�