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STATE OF CALIFORNItS WATER RESOURCES CONTRONK MPARD FORM `B': UNDTANK PERMIT APPLICATION ND STORAGE IL FORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. F-11 N ERMIT F-13 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ONE ITE ,�, 2/INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK RE Eq 02- ARM TANK-YES NO Lys z FACILITY/SITE NAME WHERE TANK IS INSTALLED L I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY' A. OWNERS TANK IDS a�SS- QVV 6 C.YEAR INSTALLED L D. TANK CAPACITY IN GALLONS' QUC' II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N C. UNLEADED ❑2 LEADED ❑3 DIESEL -13 CHEMICAL PRODUCT 4 OIL A. MOTOR VEHICLE FUEL 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN IT/EM D,BELOW) 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME�a / C.A.S.g /3 N HAZARDOUS SUBSTANCE STORED&C.A.S.H Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OFO ❑ 1 DOUBLEWALLEO 3 SINGLEWALLED WITH EXTEflIORU. 5 UNKNOWN SYSTEM l74 ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO W/RBERGLSS REINFORCED PLASTIC B.TANK Ae ❑ /� 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERI `"/ ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN El W OTHER ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLICUNING C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED [pl9LUNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLEW1TH 100%METHANOL O YES 0 ❑99 OTHER D. CORROSIO ❑ I POLYUHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE re95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE SYSTEM TYPE / A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER A A SINGLE WALLIED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER B.CONSTSYSTEMIUCTI /yam A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 100%METHANFIBERGLASS L C. MATERIAL/qi 1 A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP /L// A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER �V. LE K DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS p 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE �.2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN NERT MATERIAL? ❑YES E] NO GALLONS L� THIS FORM HAS BEEN COMPL ED 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 CY X COUNTY# JURISDICTION# AGEN FACILITY ID N n;7 TANK ID X a a a- S 0 0 PHONE t WITH AREA CODE CU NT LOCAL AGENCY FACILITY IDX ppP VED BY NA /� MIT APPROVA DATE PERMIT EXPIRATION DATE PERMIT NUMBER REC CNECKX PERMIT AMOUNT SURCHARGE GE T. FEE CODE EIPT0 BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI . A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY