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STATE OF CALIFORNIA WATER RESOURCES CONTRO OARD "•w. FORM B': UNDE&OUND STORAGE TANK PRO AM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 11 110 MARK ONLY -❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Ul CHANGE OF INFORMATION ❑7:MANENTLY ANK ONE ITEM 2 INTERIM PERMIT ❑I AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 K RENO W I FACILITY/SITE N ' _AYE WHERE TANK IS INSTALLED: 'j' ea � M TANK-YES NO ❑ IV / 7 0 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 7S37Ni co to A70WNERS TANK ID B B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: :j GJ 11. TANK CpFhTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,90MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL [__j 2 PETROLEUMB. � / C. 1 UNLEADED E]2 LEADED E:]3 DIESEL ❑3 CHEMICAL PRODUCT ❑ I OIL N ,RDQUCT ❑I GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑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 6 CAS,F CA.S.E: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑1 DOUBLEWA LED ❑3 SINGLE WALLED WITH WEROR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILS ❑I SECONDAW CONTAINMBR ❑99 OTHER ❑1 STEE1/070N ❑2 STANLESS STEN ❑3 FIBFR30M ❑ 1 STEEL OAD W/RBERGLA35 REINFORC®PLASTIC B.TANK ❑5 0MUUEIE ❑6 POLYVWTL(HLORDE ❑7 AIUUNUIJ ❑ B 180%UMMNOL COMPATIBLE FAP MATERIAL ❑9 BflON7E ❑10 GALVANIZED Sft$ ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RIBBBILM ❑2 A(KYOLNING r-13 EPDXYUNING E:] 1 PHENOLIC LINING C LININGS ❑5 CRASS LNNG ❑6 UNLINED ❑95 UNKNOWN ❑ BINNGLMTERALCOWATIBIEM1110%kiU MNOL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLMHLMWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑1 RBFAGASS RDWOROED PURSING PROTECTION ❑5 CATHODIC PWIECIIONN ❑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 DOUNLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 1009E 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 8 FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P B I VISUAL CHECX P S 2 INVENTORY RECONCILIATION P B 3 VADOSE WEDS ► B I ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P B e PRECISION TESTING P B 7 PRESSURETESRNO P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOM) 2. ESTIMATED QUANTITY OF 3.WAS TANK FLLLED.WITH SUBSTANCE REMAINING N- OALLOMS WERT 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 I JURISDICTION B AGENCY I FACILITY ID E TANK ID B = = I I I q7F/-P CURRENT LOCAL AGENCY FACILITY ID APPROVED BY KAYE PHONE I WITH AREA CODE K 2 PERMIT NUMBER PERYITAPPROVAL DATE PERMIT EXPIRATION DATE 19 //'�� `,TL`1 CMECKI PERMIT AMOUNT RCHARGE AMT. FEECODE -CEIPTI BY:W1&1� \v H3RM B Ne-29ae) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED