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STATE OF CALIFORN0 WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TANK PRCRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY ID ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED � t HDF� FACILITY/SITE NAME WHERE TANK IS INSTALLED: '2 3 0 �� 'N A 11V s ,(/ RM TANK-YES❑ NO �r I. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-SO SPECIFY Gf'�ij�� •O A. OWNERS TANK IDE ' B. MANUFACTURED BY: C. YEAR INSTALLED O. TANK CAPACITY IN GALLON 0 0 II. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. O C74, A. ❑ 1 MOTORCHEMICAL PRODUCT ❑2 P OLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 P UCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY [-] 95 UNKNOWN 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.E C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR LINEA UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ /IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ IO GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑2 ALKYDLINING ❑ 3 EPDXY LINING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OT D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE a I SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I'U .CONSTRUCTION A U I 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE Cl MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEEL CLAD W/FRP A U B 100%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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 0 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 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/YR) 2. ESTIMATED QUANTITY OF - 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [DNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY C� JURISDICTION � AGENCY# FACILITY IDE ONK©E . Q CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE F WITH AREA CODE PFAMITNUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE /o-y 90 CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE COD! RECEIPT/ FORM B IB-29-BS) THIS FORM MUST BE ACCOMPA JY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A LURRENT FORMA' HAS BEEN FILED rAT• �onr�c� • +nom