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STATE OF CALIFORK 1 WATER RESOURCES CONTf_. BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM i TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ON;NAM;EWHERE 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSE K I O ONE ITE2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITTANK IS INSTALLED: IV WFARM TANK-YES❑ NO ❑ .p I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9 2O Cn A. OWNERS TANK ID# B. MANUFACTURED BY: ule_ -d 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 P OLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 FUEL ❑6 AVIATION GAS Ll5 HAZARDOUS ❑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.# T 0 C.A.S.#: 17,,193f_ 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑1 BLE WALLID ❑3 SINGLE WALLED WITH FXTBIIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS ST EEL ❑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 ❑95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING /P OUC LINING LINING ❑ 5 GLASS LINING ❑8 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 10D%METHANOL? ❑YES ❑NO OTHER W D CORROSION ORRO I ON ❑5 CATHODIC FO7ECTION ❑91TAR OR NONE SHALT ❑3 UNKNOWN ❑ 4 FIBERGLASS 99 REINFORCED PLASTIC PROTEIV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A 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 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U fi 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AP:= U 95 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. Si VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 07 S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER II VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOLAR) 2. ESTIMATED GUANTITY OF GALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑VES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3� I DUB o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE OGG�'O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK# PERMIT AMOUNT I SURCHARGEAMT. FEECODE RECEIPT# BY: FORMB(6-29-60) THIS FORM MUST BE ACCOMPANIE91on FACILITY/SITEAPPLICATION, FORM 'A!,UNLESS A W RENT FORMA' HASBEENFILED DATA PROCESSING COPY