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STATE OF CALIFORNIA& WATER RESOURCES CONTRO•ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM `+ TANKTANK PERMIT APPLICATION INFORMATION w COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z _ 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E] W 8 TANK REMOVED /� FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z 00 N" �Gf ARreM77TANK-VES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# I I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: v- I1. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL F-11 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY NKNOWN ❑ 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.# C.A.S.#: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA,B,C,BD A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEANKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ i STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE7 ALU ❑8100%METHANOL COMPATIBLE REP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER F-11 RUBBER LINED E]2AUCYD LINING ❑ 3 EPDXY LINING n 4DWSROLIC LINING C. INTERIOR LINING F-15 GLASS LINING F76 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ i POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 5 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 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED. A U 3 LINEQTRENCH A U 9) NONE # U5 UNKNOWN A U--99OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U -3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U -5 ALUMINUM AA.CONCRET,F„ A U 7 STEEL CI-ADW/FHP A U 8100%METHANOL GOMPATIRLE 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 B I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P CTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 5 KNOWN P S 99 OTHER- VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 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# CURRENT LOCAL AGENCY ACITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER ,I^/ U G PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Lj %J CNECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �1-4D FORM B(6-29-Re) THIS FORM MUST BE ACCOMPANIED-FY A FACILITY/SITE APPLICATION, FORM `A',UNLESS AWENT FORMA' HAS BEEN FILED DATA PROCESSING COPY