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STATE OF CALIFORNa WATER RESOURCESCONTROARD FORM `B': UNDERGROUND STORAGE TANK PR RAM TANK COMPLETE PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. t C] MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�DTT NK ONE ITEM ❑ 2 INTERIM PERMIT F__] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑0 TANK REMOVED IL FACILITY/SITE NAME WHERE TANK IS INSTALLED: S �� ,fon/al .S'% S�k ARM TANK-YES❑ NO .ai 00 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK ID a B. MANUFACTURED BY: iw�y i 1, /YJccyf T C. YEAR INSTALLED j4 5 1 D. TANK CAPACITY IN GALLONS: X067 cll 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 OTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. El UNLEADED ❑2,,,LEETTTATTTDED ❑ 3 DIESEL 3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 UEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS - [-] 80 EMPTY [:] 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ,_L�_, 9999 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER C NAME OF HAZARDOUS SUBSTANCE STORED& A.S.# C.A.S.#: 6 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED F-]3 SINGLE WALLED WITH EKTERIOR LINER ❑ 95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER i STEEUIRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 19096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ ❑1 RUBBER LINED LKYDUNING F-13 EPOWUNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP 2TAR OR ASPHALT ❑3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 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& 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 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 1.ESTIMATED DATE LAST USED(MO/VR) 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# am = = 1010 / z ___ 5 DvG3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT... AMT. FEE CODE RECEIPT# BYG� /D ZU FORM B(5-29-a8) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA HAS BEEN FILED DATA PROCESSING COPY