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STATE OF CALIFORNI4a WATER RESOURCES CONTRO�OARD FORM `B': UNDE ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Ns.7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / N FACILITY/SITE NAME WHERE TANK IS INSTALLED: �' - W fls aY\ ARMTANK-YES NO 0 I. TANK DESCRIPTION COMPLETE ALL UNKNOWN-SO SPECIFY A. OWNERS TANK ID# G OSI 1�Ob( B. MANUFACTURED BY: T/� / U 1 D. TANK CAPACITY IN GALLONS: 1 A C.YEAR INSTALLED U U. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F-1i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �ODUCT ❑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 C.A.S.0 HAZARDOUS SUBSTANCE STORED 6 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D A.TYPE OF ❑ I DOUBLE WALLED ❑3SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN V , SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT99 OTHER t•'"''' ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑ 3 RBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81DD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL N95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC UNING C LINING INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 1<95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP ❑2TARORASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 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 A U 3 GRAVITY A U 91 NONE A U 96 U OWN 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 NO A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 IPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE A NKNOWN 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 S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSEWELI 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 5 7 PRESSURE TESTING P 8 91 NONE PS UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED ppppppppTE LAST USED(MO/YR) 2. ESTIMAGALLONS AND QUANTITY OF 3.WAS TANK FILLED WITH Ay( I M� SUBSTANCE REMAINING IN INERT MATERIAL? YES W NO W THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JURY,AND TO TH ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANCS NAME IF NTED851G4LATURE) - DATE Rt' I/ vi 1L4/A11�1 !![[VV''LLNNAA LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY k FACILITY ID# TANK ID k 3 q � � a s3 0 © o i APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# O 'Y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE CEIPTM BY: G/p/ ^V1L�_}tI FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS I: HRENT FORMA' HAS BEEN FILED Of fl DATA PROCESSING COPY