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STATE OF CALIFORNI WATER RESOURCES CONTRI BOARD FORM 'B'- UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK [FACILITY/SIT;E ARK ONjWHER;ETANK W PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY NE ITEERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV NAIS INSTALLED: AdI 3.1 B#g'NT ARM TANK-YES NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANKIDR D. TANK CAPACITY IN GALLONS: U C.YEAR INSTALLED ilk II. TANK CONTENTS IF(A.I),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ED�5 EHICLE FUEL ❑2 PETROLEUM L PRODUCT ❑4 OIL ❑ 1 PRODUCT "❑4 GASAH0 ❑ 5 JET FUEL ❑8 AVIATION GAS OUS ❑80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL99 OTHER(DESCRIBE IN ITEM D,BELOW) VEHICLE FUEL,ENTER NAME OF C.A.S.W UBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,SD ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EX01OR LINER 95 UNKNOWN A.TYPE OF SYSTEM F-12 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑M OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCLADWIRBERGLASS REINFORCED PLASTIC B.TANK ❑5(pNCRER ❑6 POLYVINYLCHLORIDE ❑7 MINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING 4 POMC UNING C.INTERIOR ❑5 GLASSUNING ❑6 UNLINED 95 UNKNOWN LINING ISUNING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ONO ❑99OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT 3 WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE CU,195 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A. CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLSP ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 1 PRESSURE TESTING P 8 91 NONE P 8 5 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.WAS TANK FILLED WITH I SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID 8 'r G' Ll / (AZI 101010 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER F PERMIT APPROVAL DATE PERMIT EXPIRATION DATE d- i3 89 CNECKM PERMITAMOUNTI SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(B-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS URRENT FORMA' HAS BEEN FILED ROCESSING COPY