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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I, Q Q Is FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY # A. OWNERS TANK ID I I B. MANUFACTURED BY: C. YEAR INSTALLED / 9 / 0. TANK CAPACITY IN GALLONS: O 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 L]3 DIESEL ❑ 3 CHEMICAL PRODUCT EU.4- IL ❑ 1 P DUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN' vTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM O,BELOW) D HAZAARDOUS SUBSTANCE STORED&C.A.S.#CLE FUEL,ENTER NAME OF LN Q5�e, 4-( C.A.S.#: C> III. TANK CONSTRUCTION MARK ONE ITEM LY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WAL D WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDA Y NTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL F-1 3 FIBERGLASS F-] 4 STEEL CLAD W/RBERGUSS REINFORCED PLASTIC MATERIAL B.TANK F-15 CONCRETE ❑6 POLYVINYL CHLORI ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYDUNING 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? S ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARGRASPHALT ❑3L WRAP ID RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 U NOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER ROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 INED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 LYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST LCI-ADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OT R V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 LECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 NKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH F��/`,, SUBSTANCE REMAINING IN '40LLONS YYY""_VV{INERT MATERIAL? ❑YES I/y NO G THISIFORMIqAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BES F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# aM = = 1 1 111311 ,3 / CURRENT L AGENCY FACILITY 10 p t4 1 7 APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT - SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(B-29-68) THIS FORM MUST BE ACCOMPAN09VA FACILITY/SITE APPLICATION, FORM 'A',UNLESS, :RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY "'