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STATE OF CALIFORNI WATER RESOURCES CONTR( RD "`+• FORM `B': UNDERGROUND STORAGE TANK PRO-GRAM COMPLETE ro: TANK TANK PERMIT APPLICATION INFORMATION 10 A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �. 30 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY CL% ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT El 6TEMPORARY TANK CLOSURE 0 8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6OO ICG `e 7 ARM(TA�NJK---YES NO ❑ Lo I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY q/ 7 7� FTI r A. OWNERS TANK IDN B. MANUFACTURED BY: L14 Ln C YEARINSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICALPRODUCT ❑4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) r D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.q: HAZARDOUS SUBSTANCE STORED&CA S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D ` A.TYPE OE OUBLE WANED ❑3 SINGLE WALLED WITH EYiEHIOR LINER 95 UNKNOWN SYSTEINGLE WALED ❑4 SECONDARY CONTAINMENT ❑99 OTHER MEUIION ❑2 STAINLESSSTEEL ❑3 FIBERS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANKONCRETE ❑6 POLYVINYLCHLORIDE ❑7 INUM ❑B 1W%METHANOL COMPATIBLE FRP MATERRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER r ❑ 1 RIIBBERUNED ❑2 AUYD LINING ❑3 EPORYUNING ❑ 4 PH IC LINING C.INTERIOR ❑5 GLASS LINING ❑6 UNUNED UNKNOWN LINING ❑ IS LINING MATETMLOOMPATIBLE WfTH10D%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYFn'JNEWRAP ❑2 TARORASPHALT ❑ INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE K UNKNOWN ❑ 99 OTHER r 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 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A(UA5 UNKNOWN A U 99 OTHER r A U 1 STEELIRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM • �6 CONCRETE A U 7 STEEL GLAD W/FRP A U B IW%METHANOL COMPATIBL EFRP A U 9 GALVANIZED STEEL 95 UNKNOWN A U N OTHER r 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 WELLSPS 5 UNKNOWN ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES E] NO GALLONS r THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICAM'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY CODUN�TAY N � JURISDICTION N AGENCY N FACILI Y ID N TANK ID N I F= E= --�Y APPROVED BY NAME PHONE N WITH AREA CODE RENT LOCAL% F.AGIRY ION A PERMIT NUMBER (//JI J� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / RECEIPT• X/B/_Y: WCHECK PERMIT AMOUNT I SURCHARGE AMT. FEE CODE -,......, vo, Tule FnCU MIMT RF ACCOMPANIED BY A FACILITY/SITE APP.ICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED