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STATE OF CALIFORN WATER RESOURCES CONT OARD •',.':. �.- FORrM `B' : UND GROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATIONo:. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.: `� •a ' MARK ONLY ❑ I 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 ❑8 TANK REMOVED 1-5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q S ��ARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY • A. OWNERS TANK ID N 3 B. MANUFACTURED BY: e4 G. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I!. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q, A. ❑ i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED [j 3 DIESEL ❑3 CHEMICAL PRODUCT IL ❑ 1 P UCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN WASTE ❑7 METHANOL E 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � r� O HAZARDOUS SUBSTANCE STORED&C.A.S.N w �-` f/ C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLS ❑3 SINGLE WALLED WITH EXTERIOR LINEA UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-1I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASSREINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE [jI ALUMINUM ❑8 1 W%METHANOL COMPATIBLE FRP �� ❑9 BRONZE ❑ 10 GALVANIZEO STEEL FZ 9 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBER UNED 2 ALKYO UNING 3 EPDXY LINING ❑4 PH OUC UNING LINING ❑5 GLASSUNING 6 UNLINED UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHIENEWRAP ❑2 TAR OR ASPHALT 03V; ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE P ❑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 NO U 5 UNKNOWN A U "OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE . A UNKNOWN A U 99 OTHER A U i STEELlRON 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 ^6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOIYR) 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 LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY# FACILITY ID N TANX ID B Q I I El I I I I L0101ON 'd3fli CURRE OCAL AGENCY FACILITY ID A APPRD D AME H� PHONE M WITH AREA CODE If a--- I f BY NAME e V/�- PERM NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT 'la8URCHARGE ANT. FEE CODE -RECEIPT II gY: I -. FORMS(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY