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STATE OF CALIFORNIA& WATER RESOURCES CONTROLMARD ".......•^^z FORM 'B': UNDER ROUND STORAGE TANK PROG AM se - - TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED A K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: Zl w7` e- Z-94�� ARMTANK-YES NO O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION B. MANUFACTURED BY: W C.YEAR INSTALLED 0 V D. TANK CAPACITY IN GALLONS: �•�(� O II. TANK C TENTS IF(A.11,IS MARKED,COMPLETE ITEM C.IF(Al S NOT MARKED,C MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED E] 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT E] B.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) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.0 C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.6 D A TYPE OF ❑ I DOUBLEWAUED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8 1W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOUC LINING C.INTERIOR ❑ 5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN LINING F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO ❑99OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT F-1 3 VINYL WRAP Ej 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION E] 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 I 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 I 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U S 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY* FACILITY ID N TANK ID M yE CURRENT LOCAL AGENCY FACILITY ID♦ APPROVED BY NAME PHONE N WITH AREA CODE /2 YI 7 5� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 2 �/ CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: FOHM B(6-29 BB) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES RRENT FORMA' HAS BEEN FIILLE` MD'' DATA PROCESSING COPY