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STATE OF CALIFORNIA WATER RESOURCES CONTROI, -?ARD FORM `B': UNDERGROUND STORAGE TANK PRO&F(AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN 'INFORMATION FOR EACH TANK. Z RO MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATIONXA�� ANK ANENTLY CL „,oANK ONE ITEM 2 INTERIM PER ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSUREREMOVEDIO FACILITY/SITE NAME RE TANK IS INSTALLED: �, W -YES❑ NO ❑ cn Ia 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED t CI D. TANK CAPACITY IN GALLONS: 1-7 II. TANK CONTENTS IF(A.2 IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OILn�RODUCT ❑4 GASAHOL ❑ SEL ❑8 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN ILLL�JJJ 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF n HAZARDOUS SUBSTANCE STORED&C.A.S.# d vD6q C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM2 NGLE WALLED 04SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE [:]7 LUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 ENOLIC LINING C.INTERIOR LINING ❑5 CUSS UNING F-16 UNLINED95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO B9OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3yJML WRAP ❑4 FIBERGLASS REINFORCED PLABOC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IFABOVEGROUND, 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 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 111.4 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. S 1 VISUAL CHECK • 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS j P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER V1. 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 INERT MATERIAL? ❑YES E]NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY IDN (/')/ 1VPERMIT Q APPROVED BY NAME PHONE#WITH AREA CODE IPERMIT NUMBER PERR IT APPROVAL DATE PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT42SURCHARGEAMT. FEE CODE FPECEIPT# BY: v �1 FORM B(629-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM,A, HAS BEEN FILED j " PROCESSING COPY