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STATE OF CAL I FO R N WATER RESOURCES CONTROARD 1♦ 5��er p�'�r FORM `B': UNDE GROUND STORAGE TANK PR SRAM Y �� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ��IFp FH MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑�8 TANK REMOVE �`7 PERMANENTLY CLOSED TANK�j ' ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ � `J FACILITY/SITE NAME WHERE LANK IS INSTALLED: ©,p (,�J 1a OARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY �J A. OWNERS TANK ID# 2, B. MANUFACTURED BY: C. YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: dU II. TANK SeNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C� Q1 A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BVl C. ❑ 1 UNLEADED [:]2 L y ED ❑3 DIESEL 4h* f7 CHEMICAL PRODUCT ❑ 4 OIL ODUCT ❑4 GASAHOL JE1 FUEL ❑ 6 AVIATION GAS Ej� ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE:STORED&C.A.S.# C.A.S.#: 1111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D A. TYPE OFUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING Ell 4 HENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑ 6 UNLINED 9 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ]ErNOTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V L WRAP ❑ 4 RBERGLASS REINFORCED PLASTPC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF A$ E GROUND, U IF UNDERGROUND,'BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 9.9 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PWC) A U 4 RBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1009E METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 95 UNKNOWN A U 99 OTHER a, V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ,f/ P S 1 VISUAL CHECK - 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i. ESTIMATED DATE LAST USED(MO/YR) T2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EHI 00 J137FO c90o CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PH WIT A EA CODE qf r v PERMIT NUMBER TPERMIT APPROVAL DATE PERMIT EXPIRATION DATE —� CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: W/?ll FORM B(3-7-68) THIS FORM BUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A c:JRRENT FORMA' HASSEEN FILED DATA PROCESSING:COPY