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STATE OF CALIFORNP WATER RESOURCES CONTR; BOARD �� '`• FORM B': " UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION ` TAN K COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. SO I MARK ONLY ❑ I NEWPERMIT ❑3 RENEWAL PERMITE"6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSE K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY TANK CLOSURE ❑8 TANK REMOVED r FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'r I �N �l l SSI ARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �i 1 A. OWNERS TANK IDN B. MANUFACTURED BY: rC 4 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: QO d I II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. i A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMVI C. E] 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑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.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.&D A TYPE OF ❑ 1 81.E WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER II 1 STEELARON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYViHYLCHLORIDE ❑7 ALUMINUM ❑8 IW%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UN$NG ❑ 3 EPDXY LINING 4 ENOLIC LINING C.LININGJim I: ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN l LINING !{ ❑S LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO OTHER tq D.CORROSION ❑ 1 POLYETHLENE WRAP [:]2 TAR OR ASPIUIL7 V96 INYLWRAP ❑ 4 FIBERGLASSREINFORCEDPLASTIC PROTECTION5 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 n SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER i B.CONSTRUCTION A Y l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A rr95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91'NONE I C MATERIAL A U 5 ALUMINUM A 401 CONCRETE A U 7 STEEL CLAD WlFRP A U S 1 DD%METHANOL COMPATIBLE FRP ` A U 9 GALVANIZED STEEL A U AS 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. f 8 1 VISUAL CHECK P 2 INVENTORY AECONCILIATfON P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATEA MONITORING WELLS �y,•� P 8 8 PRECISION TESTING 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN p $ 99 OTkER 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,1S TRUE AND CORRECT. 1 APPLICANT'S NAME(PRINTED 8 SIGNATURE) GATE LOCAL AGENCY USE ONLY r COUNTY N JURISDICTION N AGENCY 8 FACILITY ID 8 Li E L LLJ TANK IDM � Od ] Zys o0o I CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY HANE PHONE f WITH AREA CppE M M Uhl . PERMIT NUMBER - PEgMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK f PERMIT AMOUNT VRCHARGE AMT. FEE CODE ":EIPT f BY: ,J' C AV FORM B(&29-W) THIS FORM MUST SE ACCOMPpNJ BY A FACIL[TYISITE AFPLIC_ATION, FOR M 'A',UNLESS A C_'RRENT FORMA' HAS BEEN FILED V l