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STATE OF CALIFORNI WATER RESOURCES CONTROARD FORM `B': UNDE ROUND STORAGE TANK PROGRAM ' TANKTANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. HrF MARK ONLY @12-1�NTERIMRFERMIT IM1T ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMAPON ❑ 7 PERMANENTLY CLOSED TANK I ONE ITEM ❑4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE ❑ ❑$TANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: c�_ �n tIA-4TARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE co A. OWNERS TANK Il)# i" �' B. MANUFACTURED BY: � C. YEAR INSTALLED } D. TANK CAPACITY IN GALLONS: (j pa 11. TANK CqWTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,C LETE ITEM D. A. E�JMOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. i UNLEADED ❑ 2 LEADED ❑3 DIESEL ElB.3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBElN ITEM 0,BELOW) D. JF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1D LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGL LEO ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER .TANK 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ I ALUMINUM ❑8 IGO%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-] I RUBBER LINED ❑2 A D LINING C. INTERIOR ❑3 EPDXY LINING El PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINY P ❑ 4 FIBERGLASS REINFOACED PLASTIC PROTECTION ❑ 5 CATHODIC PPOTECTPON ❑ P NONE NKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 95 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 A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U)5 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 S 1 VISUAL CHECK 5 2 INVENTORY RECONCILIATION �CLOS�EDIN ELLS PP 5 7 PRESSURP VI. INFORMATION ONTANKPERMANENTLY PLACE 1, ESTIMATED DATE LAST SED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING 1N INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLFDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE:) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I I E Ecdcdc-7;1C CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE e -- — j o L2-e'k 4�K— PERMIT NUMBER PERMIT APPROVAL DATEPEp T EXP)RATION DA CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-a8) THIS FORM MUST BE ACCOMPANI M A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AM11WIRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY