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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD F^ FORM 'B' UNDERGROUND STORAGE TANK PROGRAM a TANK PERMIT APPLICATION INFORMATION JANK 'N COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. E LJ MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑2INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED { W FACILITY/SITE NAME WHERE TANK IS INSTALLED: l GJ U 5 . �fGRk 61 M G/IARN TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 7 CLS A OWNERS TANK ID N B. MANUFACTURED BY; 7 CD C.YEAR INSTALLED J4 D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. VI MOTOR VEHICLE FUEL 2 1 UNLEADED ED 1�4 IESEL A. ❑ 3 CHEMICAL PRODUCT 1 0&flOIEUM 6. 1 Pfl000CT C ❑1 GASOHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑60 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&CA.S.N C.A.S.If: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOE A,B,C,a D A.TYPE OF - ❑ 1 DOUWWALIB) ❑s BNGIEWADFDWITHEXTERIORLINER ❑95 uwcNowN SYSTEM, ❑2 SINGLE WALED ❑4SECONDARYCONTAINMENT ❑99 OTHER ❑ 1 UEELIMN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑N STEEL CUB W/FIBERGLASS REINFORCED PLASTIC S.TANK MATERIAL. r75 CONDEIE f76 POLYVINYL CH.OROE ❑ 7 ALUMINUM ❑8 1 Wit METHANOL COMPATIBLE FRP ' � ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RBBERLNED ❑2 ALKYO UNNG ❑3 EPDXY LNING ❑N PHENOUC UNNG LINING ❑5.amumm ❑6 UNLINED ❑95 UNKNOWN ISH NMWTBYALCOMPATIBLEWITH100%METNMa? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHIHEWRAP ❑2 TAR OR ASPHALT r-13VINYLWAAP ❑N FIBERGLASS REINFORCED PLASTIC PROTECTION_ 5 CATHOLIC P90TECTION E]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 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 81 OD%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 8 1 VISUAL CHECK P & 2 INVENTOR!RECONCILIATION P 6 3 VADOSE WELLS P i N ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P & 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P i 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) _ 2.ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? Ej YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUGANi'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID Y TANK ID N 3 9' T t7i i) 5 1 ! CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE F WITH AREA CODE yA-nlp Y 11 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / CHECKII PERMIT AMOUNT RCHARGE AMT. FEE CODE EIPT 1 BY: ♦�` FORM B IS-2"s) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED