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STATE OF CALIFORNI%o WATER RESOURCES CONTROOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWINq INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 0 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7�jL1. / ARM TANK-YES❑ NO z 9SI o 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY "ZC A. OWNERS TANK ID# 8. MANUFACTURED BY: C. YEAR INSTALLED U 0. TANK CAPACITY IN GALLONS: < IL TANK EONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL 2 TROLEUM B. C. ❑ 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL 4 F-13 CHEMICAL PRODUCT 4 OIL RODUCT ❑4 GASAHOL 4 5 ET FUEL ❑6 AVIATION GAS F-15 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# ljVd m I C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF UBLEWAUED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LK 2 SINGLE WALLED ❑4 SECONDARYOONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 BIEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE n 7 AAINUM ❑ B 100%METHANOL COMPATIBLE FAP MATERIAL ❑ LrQ�'9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTJJJJH��ER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHE OLICUNING C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED ,� UNUNKNOWN LINING ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 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 ACVb ACVGRAVITY A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVCI A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 1I1,6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 995 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. PC P 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTI S 7 PRESSURETESTING P S 91 NONE P S 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 INERTMATERIAL? ❑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&SIGNATURE) DATE LOCAL AGENCY USE ONLY �C�O�OU�NTYYY## JURISDICTION# AGENCY# FACILITY ID# TANK ID# '-'-T ±APPROVEDI0o AME/ � 6PHO�p WI�ARoODE CURRENT LOCAL AGENCY FACILITY ID pAM& Da SPERMIT NUMBER PERMIT ATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMTFEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIEU BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY