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STATE OF CALIFORNIP WATER RESOURCES CONTRO' 'OARD FORM `B': UNDEftROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY D31';`NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I O FACILITY/SITE NAME WHERE TANK IS INSTALLED: IffadARM TANK-YES❑ NO Ifflip I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID NB. MANUFACTURED BY: C. YEAR INSTALLED 7 7,2-- D. TANK CAPACITY IN GALLONS: A I II. TANK CgfiffENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-4. ca A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL B. A ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 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 S.N 6 C.A.S.N: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,AD i A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN 9' ! SYSTEM ❑2 SINGLEWALLED ❑1 SECONDARY CONTAINMENT ❑'93 OTHER 5IEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PAASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 1 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ IO GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHEN CLINING LINING ❑5 GUSSUNING 6 UNUNED C.INTERIOR NKNOWN ❑ ❑IS LINING MATERIAL COMPATIBLE NTH 1DD%METHANOL? [:]YES O NO ❑99 OTHER D. CORROSION ❑ I POLYETHIENEWRAP ❑2 TAA OR ASPHALT IWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A FUq SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A?M5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U T STEELCLADW/FRP A U 8 10D%METHANOLOOMPATIBLEFRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEq(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS I, SUBSTANCE REMAINING IN INERT MATERIAL? [-]YES ❑ NO THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID R O0 1 / j 9 OO 10 3 CURRENT LOCAL AGENCYY ITY IDj APPROVED B NAME PHONE N WITH AREA CODE � � U PERMIT NUMBER PERMIT APPROVAL DATy PFkMITEXPIRATONDATE O CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE L RECEIPT N BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPAN FACILITY/SITE APPLICATION, FORM PA',UNLES NT FORMA' HAS BEEN FILED DATA PROCESSING CO