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STATE OF CALIFORNI40 WATER RESOURCES CONTROOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION 0COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED NK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6?(� /�(, TEMPORARY TANK CLOSURE [—]8 TANK REMOVED dr FACILITY/SITE NAME WHERE TANK IS INSTALLED: l� e S/vC ARM TANK-YES❑ NO -7 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9O A. OWNERS TANK IDA V It B. MANUFACTURED BY: Qk- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (, 20 11. TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. c" A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT E] 4 OIL 1 PRODUCT ❑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 HAZARDOUS SUBSTANCE STORED 8 C.A.S.P C.A.S.X: 411. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 'GL WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND WIFIBERGNSS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 MINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL [—]9 BRONZE ❑ 10 GALVANIZED STEEL %UNKNOWN ❑ 99 OTHER F-11 RUBBERUNED ❑ 2ALKYD LINING ❑3EPDXY UNING n 4JHENOUCUNING LINING ❑ 5 GLASS UNING 6 UNLINED C. INTERIOR 95 UNKNOWN ❑ ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YE'S', ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT n 3ymI!LWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LY95 UNKNOWN [:] 9R 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE( C) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B I0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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�/ P 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS `,Y1 P S PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION R AGENCY 8 FACILITY ID a TANK ID k CURRENT LOCAL AGENCY FACILITY iU%/ APPROVED, NAM �!� PHONE M WITH AREA CODE km Nfm PERMIT NUMBER 5 PERMIT APPROVAL DATE S ERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT x BY: Idi \v-nv'II FORM B(3-7-BB) THIS FORM UST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A URRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY