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STATE OF CALIFORNIO WATER RESOURCES CONTRq&OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1!!fORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED S FACILITY/SITE NAME WHERE TANK IS INSTALLED: T Q ARM TANK-VES❑ NO .,.' 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC FY 0 A. OWNERS TANK ID# I 2= FACTU . MANURED BY: B !!ll C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ooV W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. / C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F--] 3 CHEMICAL PRODUCT F-] 4 OIL -j�{/PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0 BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED&C.A.S.# �� CA S,#: KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&O A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER gKNKNOWN SYSTEM ❑ 2 SIN GL WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER Ev 1 BTEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 RBEIIGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-77 ALUMINUM E]8 IW%METHANOL COMPATIBLE FRP MATERIALMATER ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENO WING C.INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED - UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE NTH IDG%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 A AP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 6J5 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 1 VISUAL CHECK (�75 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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 1. ESTIMATED DATE LAST USF[ (MO/YR) 2. ESTIMATED QUANTITYOF 3. WAS TANK FILLED WITH N SUBSTANCE REMAINING IN INERT MATERIALS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � = 1 O6) 1 / I h I / U vo o CURRENT LOCAL AGGI Y FAC ITY 1 APPROVED BY NAME 2 HONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL 91ATE/ RMIT E% RATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BEACCOMPANd BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY is