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„. y'�cc;- . .�T�-=-Kior�+afstiyr�r .. ' '•' Y�1 - -: �sr,�,�l”-�'q,w .. r,,,.^p+ilesa+_.._. .. STATE OF CALIFORN ,v WATER RESOURCES CONTRC-'30ARD ,•`':��.'�� FORM 'B': UNDERGROUND STORAGE TANK PROVRAM -�� TANK PERMIT APPLICATION INFORMATION! ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I C. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 WRMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE 8 TANK REMOVED m 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES NO m G: 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: u m I` C. YEAR INSTALLED 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. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ i PRODUCT ❑4 GASAHOL E] 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.If C.A.S.k: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,A D A.TYPE OF ❑ i DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER g2jrb UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 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_ VUNKNOWN ❑99 OTHER i' 1 RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4 PtJENOUC LINING C.INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 424UJ95 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 5 UNKNOWNA 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 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 OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. -7 APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY S FACILITY ID M TANK IO M 1 ] El I I I 66 131 -076-1 LO I JT CURRENT LqCALAGENCY FA ILITY ID S APPROV D BY NA E PHONE 0 WITH AREA CODE a PERMIT NU BER PERMIT APPROVAL DA 11PEAurr EXPIRATION DATE 1 CHECK II PERMIT AMOUNT SURCHARGE ARlT. FEE CODE RECEIPT II BY: L FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIED Y A FACIL117/SITE APPLICATION, FORM `A',UNLESS A RRENT FORk1'A' HAS BEEN FILED DATA PROCESSING COPY