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STATE OF CALIFORNI/ WATER RESOURCES CONTRO ARD FORM `B': UNDERGROUND STORAGE TANK PRO AM �A TANKTANK PERMIT APPLICATION INFORMATION CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY E1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1,/' w RM TANK-YES❑ NO Z I. TANKOESCRIPTION COMPLETEALL ITEMS-IF UNKNOWN-SO SPECI IC A. OWNERS TANK ID If L B. MANUFACTURED BY: C. YEAR INSTALLED 420 1 D. TANK CAPACITY IN GALLONS: 141., w0 II. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),ISNOT MARKED,COMPLETE ITEM D. W A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ` B. C. 1 UNLEADED w ❑ B'CDCDED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑q OIL 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.# " C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLE ALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B.TANK TEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXYLINING ❑4 PHENOLICUNING LINING ❑5 GLASSUNINGLINED > ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑''Z TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE [;J-9IINKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CI CLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A II SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTIN S 7 PRESSURE TESTING P 8 91 NONEP 8 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 FlLLI WITH vlgSUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ,3 O lo o Z CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME ' PHONE#WITH AREA CODE PERMIT NUMBER PERMITA ROVALDATE ERM EXPIRATICINDATE CHECK# PERMIT AMOUNT SURCHARGE T. FEE CODE RECEIPT# BY: ddk FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM 'A',UNLESS A L.._.RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY