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STATE OF CALIFORNIA WATER RESOURCES CONTROL RD FORM `B': UNDER OUND STORAGE TANK PRO M TANK TANK PERMIT APPLICATION INFORMATION 'am COMPLETE A SEPARATE FORM WITH THE FOLLOWI FORMATION FOR EACH TANK. _- Z �! oP~ 10 MARK ONLY IJX NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TANK ONE ITEM �❑ 2 INTERIM PERMIT r—] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 3� E /Vj j} /J �/4v QpRM TANK-YES❑ NO w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9SZ� O A. OWNERS TANK ID# B. MANUFACTURED BY: 7"#1�1 a degA NecoIt CID C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / 2,_&700 II. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A 1 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. [:] 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-] 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(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF fv I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER '1 STEEUAON E] 2 STAINLESS STEEL F--] 3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE E] 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ED 8100%METHAN CO PATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL [:] 95 UNKNOWN 9 OTHER 1� 51 C. INTERIOR F--] 1 RUBBER LINED ❑2 ALKYD LINING F--] 3 EPDXY LINING 714 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I DO%MEIHANOL7 ❑YES ❑ NO EI ] 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP [:] LI 2 TAR OR ASPHALT ❑3 VINYL WRAP /y4 FIBERGLASSW#WeR0iWW#110. CoA, PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 7�a OTHER IV. PIPING INFORMATION CIRCLE A IF ABK GROUND U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 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 NO A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 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 B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL P 3 4,=MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 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 INERT MATERIAL? ❑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 COUNTY# JURISDICTION# AGENCY R FACILITY 10# TANK ID M = lololiMMTF lololoill CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE TERMIT EXPIRATION DATE 3- CHECKS PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT# BY:� fJ oRM B(s-2s-Be) THIS FORM MUST BE ACCOMPANIE SY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'W HAS BEEN FILED DATA PROCESSING COPY