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STATE OF CALIFORNI(a NK O WATER RESOURCES CONTROARD FORM 'B': UNDE GROUND STORAGE TAPR1 AM TANK TANK PERMIT APPLICATION INFORMATION $° COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. ^" Z 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RMANENTL A ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK RE MOV U , W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 /GQ �' ARM TANK-YES❑ NO ("V 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID R B. MANUFACTURED BY: Ch &AI(j/ 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / QOQ II. TANK TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(a1),IS NOT MARKED,COMPLETE ITEM D. A. Mr, MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL e. 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO 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.P C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL71RON ❑2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYWNYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBER UNED ❑2 ALKYD UNING ❑ 3 EPDXY UNING 1[:]l4 P NOUC LINING LINING ❑5 GLASSUNING ❑6 UNLINED UN WN E]IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO OTHER D. CORROSION ❑ I POLYEIHLENE WRAP ❑2 TAR OR ASPHALT 3 V WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFOR! A N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 'U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A YnCONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VAOOSE WELLS P S /ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS .IvkjP 6 PRECISIONTESTING P S 7 PRESSURETESTING P S 91 NONE P A 95 UNKNOWN P S 99 OTHER VI. NFORMATION 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 OALLONB INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT5 NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION N AGENCY& FACILITY ID# TANK ID N (9 1 d0 (> U CURRENT LOCALAGENCY FACILITY ID• ^ APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBERT^ A\S1 �p PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: 0�1 FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIEDBYAFACILITYISITE APPLICATIOACURRENT FORMA HASBEENFILED DATA PROCESSING COPY