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STATE OF CALIFORNIA* WATER RESOURCES CONTROLfAMRD FORM `B': UNDERGROUND STORAGE TANK PROG A TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY En"i,NEW PERMIT F-1 3 RENEWAL PERMIT L] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYrED TA K ONE ITEM --] 2 INTERIM PERMIT -1 4 AMENDED ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE C ED F F c FACILITY/SITE NAME WHERE TANK IS INSTALLED: (& FARM TANK-YES D NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN 63 B.�MANUFACTURED BY: C. YEAR INSTALLED l!T4 D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. =-,-MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C ❑ 1 UNLEADED -E�:1-2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-] 4 OIL ffl--1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [:] 5 HAZARDOUS [:] 80 EMPTY 0 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.4 AZ,1,6 C.A.S.4: AJIA Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,&D A. TYPE OF F-1 I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM K��ffSINGLE WALLED ❑ 4 SECONDARY CONTAINMENT E:] 99 OTHER 9-1-STEEL/IRON F-1 2 STAINLESS STEEL F-] 3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-] 5 CONCRETE F-1 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM F-] 8 100%METHANOL COMPATIBLE FRP MATERIAL 1:1 9 BRONZE 1:1 10 GALVANIZED STEEL [:] 95 UNKNOWN Ej 99 OTHER C. INTERIOR F-] 1 RUBBER LINED F-1 2 ALKYD LINING F-] 3 EPDXY LINING F-] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING n-6--UNLINED El 95 UNKNOWN�t4-� [:] SUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO [E 99 OTHER D. CORROSION ❑ 1 PoLYETHLENE WRAP F-] 2 TARIORASPHALT F-] 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 2-9-1-NONE ❑ 95 UNKNOWN E] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABO GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U -1 SUCTION A(U /PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(U,/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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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. ESTI ATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY 0 3,WAS TANK FILLED WITH SUB �VAINING IN GALLONS INERT ERIAL? E:]YES [:] NO E2A I IL4 i7tA 7'HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF WJURY,AND TO THE BEST OF MY KNO'WLtDGE, IS TRUE AND CORRECT. IAPPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGEINICY# FACILITY ID# TANK ID# -7 L L CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE WAT25y� V-.� lif- -3// PERMIT NUMBER PERMIT APPRQVALPATE P RMI EXPIRATION DATE � l*-' 3 1 to e I CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS AOFTENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY