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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK / TANK PERMIT APPLICATION INFORMATION RVMYLC I CA iCYAMAI C YUMM WI IN I MC fULLUWINU IDWUMMA I IVN fUM CAOM I ANK MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC}LO�rK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3QgerG./ %iC TANK -YES ❑ NO TANK DESCRIPTION COMPLFTFA[IITFMS- IFIINKNnWN—ROSPFCIFY A. OWNERS TANK ID# B. MANUFACTURED BY: UK El1 UNLEADED LEADED ❑ 3 DIESEL C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: o II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF IA.1). IS NOT MARKED. COMPLETE ITEM D. A. Egl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. B. El1 UNLEADED LEADED ❑ 3 DIESEL F--]3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM 0, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B, C, & D A. TYPE OF ❑ OUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARYCONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ fi POLYVINYLCHLORIDE ❑ ALUMINUM ❑ B 10D% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASSUNING ❑ 6 UNLINED A Y NKNOWN 8 100% METHANOL COMPATIBLE FRP [-]IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑ YES [-]NO �THER D. CORROSION ❑ 1 POLYEIFHLENEWRAP ❑ 2 TARORASPHALT LWRAP F]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L-tl 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE COUNTY # JURISDICTION # A. SYSTEM TYPE A 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 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CURRENT LOCAL AGENCY FACILITY IDN A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CUD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN J66 A U 99 OTHER .EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 5 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED( MO/YR) 2. ESTIMATED OUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? D YES ❑ NO THIS F( HM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND Cl APPLICANT'S NAME (PRINTED & SIGNATURE) DATE RRECT. LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE #WITH AREA CODE PERMIT NUMBER CHECK # I PERMIT AMOUNT PERMIT APPROVAL DATE SURCHARGE AMT. PERMIT EXPIRATION DATE FEE CODE I ^�CEIPT# BY: FORM B (e-29-98) THIS FORM MUST BE ACCOMPANI@IT'BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY W W 0 fV 00