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STATE OF CALIFORNL WATER RESOURCESCONTRq".,DARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ,�. ... TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED T K ONE ITEM F-] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 Q 570 . s { _ ;CRM TANK-YES NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-30 SPECIFY 7. U'1 A. OWNERS TANK ID N ' B. MANUFACTURED BV: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 ,TOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. El1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 J EL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.K - C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C,A,D A TYPE OF ❑ BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER 191EEUIRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑ 4 MEL CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK U�/5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ HENOLIC LINING LINING ❑5 GLSSUNING ❑6 UNUNED NNNOWN ❑ ISUNING MATERIAL COMPAT18LE MTH 100%METHANOL2 ❑YES [:] NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 M P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 %UNKNOWN A U %OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 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 C. MATERIAL A U 5 ALUMINUM A ,U-,6 CONCRETE A U 7 STEELCLAD W/FRP A U B ID METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A D 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. J P 6 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S I 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 13AlL0149 INERT MATERIAL? ElYES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION A AGENCY N FACILITY ID M TANK ID X 10101 /E / Doo / CURRENT LOCAL AGENCY FACILITY IQ S APPROVED BY NAME PHONE P WITH AREA CODE I 1 m-` V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK P PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT• BY. FORM R(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED