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STATE OF C'ALIFORN? - WATER RESOURCES CONTR' 130ARD FORM 'B': UNDEOGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ~ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONE IOTEMY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT a5 CHANGE OF INFORMATION 7 PERMANENTLY c•.,.o.N ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED CLOSE TAN 2 INTERIM PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z / L (( ARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: �- Go�llR1G C. YEAR INSTALLED I { D. TANK CAPACITY IN GALLONS'. SO / 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. co A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN 0 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.# �TI5 QI1. CAS #: IL16.IE x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D �l A. TYPE OF vkI DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER F-11 STEBUIRON ❑2 STAINLESS STEEL a 3 FIBERGLASS E]4 STEEL GAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM [:] 6100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEEL. ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-1 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ®6 UNLINED F-�95 UNKNOWN E ISUNING MATERIAL COMPATIBLE WITH IDD%METHANOL? [:j YES [—]NO 99 OTHER D. CORROSION ❑I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 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 (vew A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A® 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A ® 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A m o FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%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 S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P® 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS ' P S 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 1 SUBSTANCE REMAINING IN INERT MATERIAL? GALLONS YES NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE l I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE GHECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-Be) THIS FORM MUST BE ACCOMPANIES.:,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AtTrRENT FORMA' HAS BEEN FILED ')ATA PROCESSING COPY