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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` w TANK TANK PERMIT APPLICATION INFORMATION -m- m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- Z 10 MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: /O ARM TANK-YES❑ NO FQ (� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY -1 A. OWNERS TANK ID X L'L —7 c5<>> B. MANUFACTURED BY: ,S 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL 1❑ 2 PETROLEUM B. C UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 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.A.S.9 C.A. .W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A. TYPE OF IL1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT i ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ERfFIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B IDD%METHANOL COMPATIBLE FRP MATERIAL ' ❑ 9 BRONZE ice' ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LNING ❑4 PH LICUNING LINING ❑5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL?; ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP IBERGIASS 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 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 / SINGLE WALLED DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM Ap CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR q tOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. IP S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 0-B 4 ELECTRONIC MONITOR P B !GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(JAO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 44QL- SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEE14 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 8 JURISDICTION# AGENCY S FACILITY ID R TANK ID X 610 1 / T CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAM PHONE N WITH AREA CODE Z�/ � 7 PERMIT NUMBER PERMITA R VALQATE PER EXPIRATI DATE CHECK N PERMIT AMOUNT SURCHARGE FEE CODE RECEIPT N BY: FORM B I6-29-93I THIS FORM MUST BE ACCOMPANIE dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 1.01RRENT FORMA' HAS BEEN FILED DATA PROCESSING CC