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STATE OF CALIFORNIC WATER RESOURCES CONTRO� ARD FORM `B': UNDERGROUND STORAGE TANK PROGM�AM TANK TANK PERMIT APPLICATION INFORMATION 6 COMPLETE A SEPARATE FORM WITH THE FOLLOWIN94NFORMATION FOR EACH TANK. _ z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT E6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / #�ARM TANK-YES NO ❑ I-a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDR B. MANUFACTURED BY: CAD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 60 ' II. TANK CONTENTS IF(A.1),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 OIL ❑ i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY �NKNOWN ❑ 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.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH!EXTERIOR LINER 144 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELPRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS F-14 STEEL CLAD W/RBFAGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ AL 7 INUM ❑610096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR I RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PH OUCUNING LINING ❑ 5 GLASS LINING ❑8 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION 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 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 U 95 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 3 ERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 5 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. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WA STANK FILLED WITH II 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID R =1 = = o7F CURRENT LOCAL AO(IACyf� Iq LITY I�R// APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 'JHI I✓T'/� PERMIT APPROVAL DATE PERMR EXPIRATION DATE CHECK II PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk FORM B(6-29-BB) THIS FORM MUST BE ACCOMPARIEUBY A FACILITY/SITE APPLICATION, FORM `A%UNLES,.-..;URRENT FORMA' HAS BEEN FILED I /X