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STATE OF CALI FO R N I WATER RESOURCES CONTRC' 'IOARD FORM `B': UNDEnGROUND STORAGE TANK PRG%.w.iAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK /CLOSURE ❑ 8 TANK REMOVED o/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 ��. / FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. 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 F-13 CHEMICAL PRODUCT ❑ 4 OIL le KiPRODUCT ❑ 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. # A C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D I A. TYPE OF ❑ 1 UBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 2 PRESSURE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL [:g"3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER PERMIT NUMBER F—]1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING O 6 UNLINED 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL CLAD W/FRP A U 99 OTHER ❑ 95 UNKNOWN �l ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3. WAS TAN FILLED WITH FACILITY ID # A. SYSTEM TYPE INE IAL? ❑ YES ❑ NO 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION qu�A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER PERMIT NUMBER C. MATERIAL A U A U A U 1 STEEL/IRON A 5"ALUMINUM A 9 GALVANIZED STEEL A U j,L U 2 STAINLESS STEEL 6 CONCRETE 95 UNKNOWN A A A U U U 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL CLAD W/FRP A U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP V LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / PVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S1 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. I FORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED (MO/YR) 2. ESTIMATED UANTITY OF 3. WAS TAN FILLED WITH FACILITY ID # SUBSTAN "�VAINING IN INE IAL? ❑ YES ❑ NO (tea GALLONS 1 1771 THIS FOhM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE 1 ()rel 0[;FNCV IISF ()NI Y COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # I I I I 1 1771 101011 1 g Iv S d oam CURRENT LOCAL AGENCY FACILITY ID # APPROV D BY Nj%Mq PHONE # WITH AREA CODE / 7,t? Apr- PERMIT NUMBER PERMIT APPROVAL DI E PE MIT EXPIRATION DATE =C� z a �l CHECK # PERMIT AMOUNT SURCHARGE AMT. - FEE CODE RECEIPT # BY: V FORM B (6-29-88) THIS FORM MUST BE ACCOMPAMY A FACILITY/SITE APPLICATION, FORM `A', UNLES RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z 10 Ab IV 00 v