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STATE OF CALIFORN' WATER RESOURCES CONTP -/ARD FORM `B': UNDIRGROUND STORAGE TANK PRMRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. _ __ Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED/ /S c FACILITY/SITE NAME WHERE TANK IS INSTALLED: Sow /L,p RM TANK-YES NO ❑ N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY gr3761 0 A. OWNERS TANK IDR t B. MANUFACTURED BY: r C.YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: I C 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 ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY V11 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF t HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,8 D A TYPE OF ❑1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E44UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 F18ERGLASS ❑4 STEELCLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE7 INUM ❑ 9100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OOTHEORLI F-1ER 1 RUBBER LINED ❑2 ALKYOUNING ❑ 3 EPDXY LINING ❑1 CUNING C. INTERIOR ,-r,"/ LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IDA%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ VM WRAP ❑4 RBERGLASS 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 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 U 96 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 ALUMINUMCONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A A U 9 GALVANIZED STEEL U UNKNOWN A U %OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S t VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 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? [::]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID R TANK ID N = = / .7 101010111 CURRENT LOCAL AOENCY FACILI IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-B6) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A OIENT FORMA' HAS BEEN FILED DATA PROCESSING COPY