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STATE OF CALIFORN ` WATER RESOURCES CONTR BOARD FORM 'B': / UNDERGROUND STORAGE TANK PROGRAM Qp Z (� TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. 1 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT n5CHANGE OF INFORMATION ❑7 PERMANENTLYC OT K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ORARY TANK CLOSURE ❑8 TANK REMOVED,/FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q Q / �W RM TANK-YES❑ NO 37 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY eHAZARDOUSSUBSTkt TANK ID# B. MANUFACTURED BY. TALLED 0. TANK CAPACITY IN G LLONS: ZOO (J 11. NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, O LEADED ITEM D. TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. Eg 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL EMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99OTHER(DESCRIBE IN ITEM D,BELOW) OTOR VEHICLE FUEL,ENTER NAME OF C.A.S.US SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.6 D A.TYPE OF DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN [ 2 SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 SER 1kT1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLWINYLCHLORDE ❑7 ALUMINUM ❑ 0100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY UNING yPHENOLIC LINING C. LI ❑LINING R F-] 5 GLASS LINING F-16 UNUNED LLLE NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLVEFHLENE WRAP ❑2TAR OR ASPHALT NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA B EGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Afy 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 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 LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P ] PRESSURE TE STING 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 E:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o ! 1S �/ 3 1010 101 / CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE c _ _ Q CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY:. FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED✓/ DATA PROCESSING COPY ,_-- I