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STATE OF CALIFORNit WATER RESOURCES CONTRO' DARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK ! TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLSED'TA ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /, FACILITY/SITE NAME WHERE TANK IS INSTALLED: E�/ R RM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS.;F UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �Q W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑d GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS VVV ❑5 HAZARDOUS ❑ 80 EMPTY ❑85 UNKNOWNF[O:] 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.R C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 102 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ ISTEELPRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE ❑8 POLYVINYL CHLORIDE MATERIAL T.6MINUM ❑6100%METHANOL COMPATIBLE FRP ru' ' C ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNER ❑2 ALKYDUNING ❑3 EPDXY LINING ❑tII6OUC LINING LINING ❑5 GLASS LINING ❑6 UNUNED JZ95 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYE1HtENE WRAP ❑2 TAR OR ASPHALT n 3 WL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E %UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(FVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 1 VISUAL CHECK G�Pl S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 6 PRECISION TESTIN B 7 PRESSURE TESTING P B 91 NONE P S 95 UNKNOWN P S 99 OTHER U VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF T WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? ❑YES ❑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 N FACILITY ID R TANK ID N 39 = = I o I o I / o I io I I p69G CURRENT LOCAL AGENCY FACTL/j�TY'ID* Q APPROVED BY NAME PHONE#WITH AREA CODE 2xyoIDvRo PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 'J � ZV CNECK# PERMIT AMOUNT _ SURCHARGE AMT. FEE CODE RECEIPT# BY: �/ FORM B(3-7-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA CURRENT FORMA' HAS BEEN FILED