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WATER RESOURCES CONTROgARD STATE OF CALIFORNIA AM FORM `B'_ UNDERGROUND STORAGE TANKFORMATION 'u .o TANK TANK PERMIT APPLICATION IN COMPLETE A SEPARATE FORM WI=MIT G FORMATION FOR EACH TANK. ' — 1 O 1 NEW PERMIT ❑ 3 RENEWALCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K HANK ONLY ❑ ❑q AMENDED TEMPORARY TANK CLOSURE 8 TANK REMOVED / wONE ITEM ❑2 INTERIM PERMIT / S A M ANK-YES❑ NO ❑ � FACILITY/SITE NAME WHERE TANK IS Ili NSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY —4 B. MANUFACTURED BY: A. OWNERS TANK ID R / D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED V D. II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C. IF(A.1),IS NOT MGRKE❑D COMFP�LDETDE ITS 2 LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ fi AVIATION GAS ❑3 CHEMICAL PRODUCT ❑27 OIL 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.4: HAZARDOUS SUBSTANCE STORED 8,C.A.S.P III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A . OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-1TEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W19BERGLASS REINFORCED PLASTIC ONCRETE ❑6 POLYVINYLCHLORIDE n 79LOMINUM ❑ B 1D0%METHANOL COMPATIBLE FRP AONZE10 GALVANIZED STEEL '�il 95 UNKNOWN ❑99 OTHER 1 RUBBERUNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ ABIOLIC LINING C.INTERIOR95 UNKNOWN LINING ❑5 GLASS LINING ❑6 UNLINED ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION F-11 POLYETHLENEWRAP ❑2TAR OR ASPHALT NYLWRAP ❑4 FIBERGLASS PEAFOPICFD PLASTIC PflOTECTION F-15 CATHODIC PROTECTION ❑91 NONE EZ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 5 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 S ALUMINUM A JI.,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A fl:v95 UNKNOWN A U 99 OTHER V. LEAK DETECTION STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / gAS 1VISUAL CHECK P 21NVENTORYRECONCILIATION P S 3VADOSE WELLS P S 4ELECTRONIC MONITOR P 8 5GROUND WATER MONITORING WELLS 6 PRECISION TESTING 8 T PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COU�UJN JURISDICTION AG FACILITY ID N TANK ID s LD �� I�TT1 v / 6 3 CURRENT LOCAL AOE CY FACILITY ID X APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER O ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE iz CHEC•Kk PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPTN (6-29-e&) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED 4�• gl DATA PROCESSING COPY