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STATE OF CALIFORNIt WATER RESOURCES CONTRA PARD "..° FORM B': UNDiftROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION I FORMATION ' ?g< COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. �� 0 !O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL0�5FABRNk ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK M VED / GJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: RM TANK-VES NO ❑ O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERS TANK ID# ' B. MANUFACTURED RY C. YEAR INSTALLED v�l D. TANK CAPACITY IN GALLONS: cjK 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 B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL / F-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS,# C A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SO%A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DGERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 AL UM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH IC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO R99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3yM4 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN E] 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 A5 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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A CONCRETE A U 7STEEL CLAD W/FRP A U 819096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A AD 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 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE S S UNKNOWN P S 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? ❑YES [:] 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [m] 10 01 I a I & 101 1ol o CURRENT LOCAL AGENC].FF CILITY_ID R APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER ,1/C�J6 •TJX o�)� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �✓D CHECKR PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECEIPTN BY: FORM B(6-29-B8) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A REIT FORM'W HAS BEEN FILED DATA Pr. FSSING COPY