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STATE OF CALIFORN& WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING1 RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION .. ONE ITEM ❑7 PERMANENTLY CLOSED TANK '- ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: N ARM TANK-YES❑ NO ❑ ,A I. TANK DESCRIPTION COMPLETEALL ITEMS-IF UNKNOWN—SO SPECIFY CD A.jOWN�ER;88TANK ID# 8. MANUFACTURED BY:JC. TALLED D. TANK CAPACITY IN GALLONS: II. TANK CO NTS IF(AMENTERNAME 1) IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A rSUBSTANCE E FUEL B. C. ❑ 1 UNLEADED D ❑ 3 DIESEL ❑ DUCT 1 PRODUCT ❑4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS F-1 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOLE FUEL, OF HAZANCE STORED 8 C.A.S.# A C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&O A TYPE OF r98R WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER RON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK TE MATERIAL ❑6 POLriINYL CHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑ ORO ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 T ASPHALT 3 WNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:15 CATHODIC PROTECTION LeIll NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 STEELCLADW/FRP A U 9 GALVANIZED STEEL A-V45 UNKNOWN A U 99 OTHER A U 8100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING P 8 7 PRESSURE TESTING P $ 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LA SE (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# CJ EKI� CURRENT LOCAL G NCY FACILITY ID# API I 3VEO BY E PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEI EKPIRATIO ATE CHECK# PERIMIT AMOUNT 8URCHARGE AMT, FEE CODE RECEIPT# BY. FORM B(6-29-aa) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICA FORM 'A',UNLESS A IiHENT fORM'A' HAS BEEN FILED DATA PROCESSING COPY