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STATE OF CALIFORV WATER RESOURCES CONTO BOARD FORM 'B': // UNDERGROUND STORAGE TANK PROGRAM #' TANK Li TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 P ANENT C T MARK ONLY ❑ ❑ ❑ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REM VIED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: U lmegd4v7"�ARM TANK.Y S❑ Ng/M-- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID q B. MANUFACTURED BY: W C. YEAR INSTALLED C� D. TANK CAPACITY IN GALLONS: d II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF( 9),ISNOT MARKED, MPLETE ITEM CA A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED WLEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 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.A CAS,q: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B IDD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD UNING F-13 EPDXY LINING ❑4 PHENOUC LINING C.INTERIOR LINING 5 GLASS LINING 6 UNLINED [:]95 UNKNOWN ❑ ❑ ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWRAP El 4 FIBERGLASS 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 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY q JURISDICTION q AGENCY q FACILITY ID q TANK ID CURRENT LOCAL AGENCY FACILITY IDN ^ � �� APPROVED BY NAME PHONE N WITH A C / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE `ECEIPT0 FOHM B(6.29-a8) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED K DATA PROCESSING COPY