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STATE OF CALIFORNI,,,, WATER RESOURCES CONTR<�)OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM rA wig! TANK PERMIT APPLICATION INFORMATION E AI Tl ■ll, COMPLETE A SEPARATE FORM WITH THE FOLLOWIN 1NPUHMAIIUN rum cAN n IAnn. w MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY0 K ONE ITEM F-12 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED:2 qg S S�ZG ARM TANK -YES ❑ NO I. TANK D ETE ALL ITEMS - IF UNKNOWN — SO SPECIFY �ILII.l . B A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED K D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS u C .c,A n IG NnT MARKPR COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL TPRODUCT ❑ 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 CAS #: HAZARDOUS SUBSTANCE STORED & C.A.S. # Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C. A D A. TYPE OF ❑/"OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM IryJ( 2 INGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 4 FIBERGLASS PIPE 9 KNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES F-1NO OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING IINrUNMA I IUN DIHGLt A IT ABuvt UMUUNU, U IF Ull-rNUNUUI`IU,ew.n.rnvv—nmu— A SYSTEM TYPE A Ul SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U95 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUU 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. 'J n8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTI NG P 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER v 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 8 SIGNATURE) DATE 1 of Al AP_CW!`V I ICC f1Nl V COUNTY # DR] JURISDICTION N AGENCY # FACILITY ID # 10101 1� TANK ID # o o l CURRENT LOCAL AGENCY FACILITY ID # F P -S 2 APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE PECEIPT N /. /� BY: (/T/ FORM B (6 -29 -Be) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED DATA PROCESSING COPY w N D7 r