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STATE OF CALIFORN'. WATER RESOURCES CONTRI.30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM `N'u TANK Z/� TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TA K ONE ITEM ❑2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV O (JJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 J RM TANK-YES NO ❑ N c 1. TANK DESCRIPTION COMPLETE ALLITEMB-IF UNKNOWN-80 SPECIFY 1>,�>& Ca A. OWNERS TANK IDR B. MANUFACTURED BY: r-o C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 11. TANK CONTENTS IF(A•1).IS MARKED,COMPLETE ITEM C.IF(A.l),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ A OIL 1 PRODUCT ❑ < GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS E]80 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.R C.A.S.W 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 UNER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWMIED ❑K SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STNNLESS STEEL ❑3 FIBERGLASS ❑ /STEEL CLAD W/FI8EAGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYWWYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1811%METHANOL COMPATIBLE FRP MATERIAL . ❑9 BRONZE ❑ 10 GALVANIZEO5TEEl ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LIED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ /PHENOUC LINING C. INTERIOR5 GLASS UNING 6 UN1NE0 E]95 UNKNOWN LINING ❑ ❑ ❑ IS UNNG MATERIAL COMPATIBLE WITH 180%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ A 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 9/ 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 R FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 81(X1%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 6 9/ NONE P 8 95 UNKNOWN P 8 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 INERT MATERIAL'! ❑YES ❑NO OALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION 8 AGENCY 8 FACILITY ID R TANK ID 8 3 g CLZ CURRENT LOCAL AGENCY FACILITY 10 8 �- APPROVED BY NAME PHONE F WITH MEA CODE 1225 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CH EOK R PERWT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT E BY: (NM Fopm9(e-sues) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED nATe ocn7•c cclnlc nnuV