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�i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ,.� �;,•;, FORM `B': UNDERGROUND STORAGE TANK PROGRAM 7AN K TANK PERMIT APPLICATION NFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWIr INFORMATION FOR EACH TANK. „a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES❑ NO'Ej z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID It dk B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ()'1 A. ❑ 1 MOTOR VEHICLE FUEL PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT OIL 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 clHAZARDOUS SUBSTANCE STORED&C.A.S.k 0� C.A.S.4: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 BLE WEED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 10 l ` LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ] 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING 4 ENOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10A METHANOL? ❑YES ❑NO ❑99 OTHER .D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE V95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE ROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A JU 13 GRAVITY A Otto,,99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH ACU 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 C.MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. PP S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P E 3 VADOSE WELLS P E 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �J1 S 6 PRECISION TESTING P 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 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 8 JURISDICTION N AGENCY N FACILITY ID M TANK ID 8 Lo lo � CURRENT LOCAL AGENCY FACILITY ID N APPROVgBY /E PHONE N WITH AREA CODE Al�PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE _T CHECK! PERMIT AMOUNT SURCHARGE AMT. FEE CODE _lECEIPTN. BY: v FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE URRENT FORM W HAS BEEN FILED DATA PROCESSING COPY