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STATE OF CALIFOA WATER RESOURCES CON*L BOARD <br /> FORM 'B'- UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY OSE NK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT �q 6 TEMPORARY TANK CLOSURE ❑B TANK REMOV <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: DO S Le S_3-7 SARM TANK-YESED-NO, u 7i <br /> •� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: k El W <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O �I <br /> n <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. v( <br /> A. ❑ 1 MOTOR VEHICLE FUEL LF-1 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED E]3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 P DUCT E] 4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE 0 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C A.S.R CA,&R: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA,B,C,A D <br /> A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT E] 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM 0100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN E]99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING � 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E] NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> 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 <br /> 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 <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY M FACILITY ID R TAANK ID N <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> �Ze d <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE � 'CEIPT/ gy; <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED I <br /> DATA PROCESSING COPY <br />