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STATE OF CAUFMp I WATER RESOURCES CONTP ' BOARD FORM 'B': UNDERGROUND STORAGE TANK PRZTGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. QpZ MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION I� 7 PERMANENTLY CLOSEDK la ONE ITEM D 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE I . L6/TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: w Tjv Q `(FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY s A. OWNERS TANK ID N B. MANUFACTURED BY: I., '-+ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: G II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,9OMPLETE ITEM D. A ffl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMki C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICALPRODUCT [:j4 OIL ppODUCT E]4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 0 80 EMPTY ❑95 UNKNOWN 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.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,BIG,&D A. TYPE OF LEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑TANK I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ NUM E]8 100%METHANOL COMPATIBLE FHP ❑9 BRONZE ❑ 10 GALVANIZED STEEL EY95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALXYD LINING ❑3 EPDXY LINING n 4 PJIENOLIC UNING LINING ❑ 5 CUSS LINING ❑6 UNLINED DR09696 NOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES [-] NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 V LWRAP ❑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 TYPEU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONECL 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 8 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 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 ' VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TESTING P 8 91 NONE P 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAYE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY k FACILITY ID # TANK ID 4 = 1010 1 11 / q I q i 1010101 CURRENT LOCAL AGENCY FACILITY ID M _ APPROVED BY NAME PHONE N WITH AREA CODE 5,4�I/�.� S PERMIT NUMBER PERMIT APPROVAL DA E PERMIT EXPIRATION DATE 'd z�- 9 CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FORM B(6-29-66) THIS FORM MUST BE ACCOM..41ED BY A FACILITY/SITE APPLICATION, FORM �A',UN.,.:A CURRENT FORMA' HAS BEEN FILED \ DATA PROCESSING COPY