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STATE OF CALIFORN11b WATER RESOURCES CONTROARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I S fdLl FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANK ID# -JF I B. MANUFACTURED BY: J,X+C_, Iv C. YEAR INSTALLED Unk-- D. TANK CAPACITY IN GALLONS: O Q(] 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑ C. CHEMICAL PRODUCT ❑ 4 OIL 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&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 GW LE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Ekf6EL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING Ea" LINING ❑ L-[J+"'"'!!5 GLASS LINING ❑ 6 UNLINED KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ED 0THER D.CORROSION ❑ I POLYETHLENEWRAP Eg4rTAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IFABOVEGROUND, 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 U 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 5 ALUMINUM ;�j 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 95 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 0 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO ) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. R APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCA GENCYAOCIL� I� APPROVED NAME PHONE#WITH AREA CODE 1� PERMIT NUMBER PERMIT APPROVAL DATE PERMIYEXPIRATlOkbATE 3 CHECK# PERMIT AMOUNTSURCHARGE ANT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIMW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY