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STATE OF CALIFOR' 1A WATER RESOURCES CON OL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM P TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ ERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: G FARM TANK-YES❑ NO ❑ W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W ul A. OWNERS TANK ID R / B. MANUFACTURED BY: a66 Url C. YEAR INSTALLED L� L D. TANK CAPACITY IN GALLONS'. w' r II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 8.4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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 8 C.A.S.R UK C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER EkfNANKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT E199 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL F-]3 FIBERGLASS MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE 6100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL NKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING 3 EPDXY LINING ❑ 4 P LIC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED Ej IS LINING MATERIAL COMPATIBLE WITH 100%METNANOL? ❑YES NO [_ 99OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E]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 SU A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U Qj!:NWN U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOW U 99 OTHER A U 1 STEEL/IRON A U 2 STAIINN�LLqESSSEESTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6 O� A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U NO N 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 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 4 6 PRECISION TESTING P S T PRESSURE TESTING 91 NO E P S 95 UNKNOWN P 8 99 OTHER j 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY IDR TANK 10 k [�Hl ffDl;� =1 fi - CURRENT LOCAL AGENCY FACILITY ID 4 PHONE N WITH AREA CODE N nJ/7 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \\ CHECK N PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT N BY: /{V/�� q \ FORM B(6 29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILEDV / DATA PROCESSING COPY