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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM .; TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING'iNFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANE CLTA K ONE ITEM ❑21NTERIMPEAMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK RE V AA Id FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q W (� 9y"U6 FARNITANK-YESLa NO O I. TANK DESCRIPTIO COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: U W C.YEAR INSTALLED V D. TANK CAPACITY IN GALLONS: rD N II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM DCO A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. [:] 1 UNLEADED 2 LEADED El 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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 8 CAS.N GAS.N: Ill. TANK CONSTRUCT!PN MARK ONE ITEM ONLY IN BOK A.B,C,A D A.TYPE OF 1:1'1 WAUE) ❑3 SINGLE WALLED WITH ExIENIDR uNER ❑95 UNKNOWN SYSTEM 2 WM1E7 ❑ 4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESSSTER ❑3 FIBERGLASS ❑4 STEEL CLAD WMBERGLASS REINFORCED PLASTIC B.TANK YMATERIALF-15 CONCRETE ❑6 POLYWNYLCHLORDE ❑7 ALUMINUM ❑6169%METHANOL COMPATIBLE FP ❑9 BONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUOBERUNED ❑2 ALKYD UNING 3 EPDXY UNING ❑4 PHENOUCUNING LINING ❑5 MUSS UNING ❑6 UNUNED ❑ IS UNING MATERAL COMPATIBLE WITH 109%METHANOL? ❑YES ❑NO one D.CORROSION ❑I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VDYL WRAP ❑4 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 U 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 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 F18ERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. kP S 1VISUALCHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS VIilP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES [DNO THIS FORM HAS BEEN 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 8 AGENCY N FACILITY ID N TANK ID N 39 = = / Ty M ZI CURRENT LOCAL AGENCY FACILITY ID N g V /7 APPROVED BY NAME PHONE N WITH AREA CODE V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EIWIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: L. FORM B(629-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY