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STATE OF CALIFORNI! WATER RESOURCES CONTRO OARD FORM 'B': UNDE?rGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWINg INFORMATION FOR EACH TANK. z MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONn 7yERM E LY CLOS ,oAN 1 O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSUREI,-��J,8 TANK REM VED(of/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z SQ SO nJ W RM TANK-Y B❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) A. OWNERS TANK ID# ('��- O B. MANUFACTURED BY: (Q C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. Q 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 EMOLEUM B. . C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL Lo J>kET FUEL ❑6 AVIATION GAS 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# O I t C.A.S.#: 6 g 6 3 0 y III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ BLE WALLED 351NGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELMON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 MINUM ❑8100%MMMOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL LLr95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBEALINED n 29LKYD UNING ❑3 EPDXYUNING 4 PHENOLIC LINING LINING ❑5 GLASS UNING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP D 2 TARORASPHALT 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE LY95 UNKNOWN D 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(UI 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 k195 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A7=GLAD W/FRP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 95 UNKNOWN AU 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. -/ P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS f�J P S 6 PRECISION TESTING P S ] 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(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I APPLICANT'S NAME(PRINTED 8SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID N APPROV D BY N ME PHONE#WITH A A COD E(/F�- 2 zi .Q" alle-f PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMITAMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM a S-29-B6) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY