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�t.r�... �:'"�� rri7� c`rr^T' yr. ' ;+��v::-;�,y�a-..N•'Jf`,7'-T`_"�a._�..�.Y_;�-.,,...Q,as.,..�n�+.r�,p..-,;-7r1-`!tia-s�a's�.:.4T,r';:.-�—�rr.::T.`r,�-,"�7�":-,-;':';r;i`:�•!s,#.rt•--'�..j-r... S A7E OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM `ANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TAN� ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: (r PVI C ARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK 10# B. MANUFACTURED BY: C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 006) CA) 11. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. (n A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM VIPRODUCT . 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL [-]4 GASAHOL ❑5 JET FUEL [:]6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [:] C 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&C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D WALLED F-]3 SINGLE WALLED WITH EXTERIOR 95 A SYSTEM ��WALLED ❑4 SECONDARY CONTAINMENT 99 O 99 OTHER WN STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIALL B.TANK r-15 CONCRETE F-16 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR El RUBBER UNER ❑2 ALKYD LINING ❑3 EPDXY LINING n AENOUC LINING ( LINING ❑5 GLASS LINING ❑6 UNLINED M95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER 0.CORROSION ❑1 POLYETHI.ENIE WRAP ❑2 TAR OR ASPHALT n Y&L WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF A!K E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AU 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 C.MATERIAL A U 5 ALUMINUM A }�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTIN S 7 PRESSURETESTING P E 91 NONE P S 95 UNKNOWN P 3 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eli] - I I I I I I I I Eolo I / I d 15-M I Dad I I CURREN OC AGENCY FACILITY IDN APPROVED BY N E PHONE N WITH AfiEA� 7 21 4 qlcl If,? PERMIT NUMBER PERMIT APPROVAL DATE PERMIf EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE .p�:E1PT N DY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED 8Y A FACILITY/SITE APPLICATION, FORM'A',UNLESS K'WRRENT FORMA' HAS BEEN FILEO DATA PROCESSING COPY