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STATE OF CALIFORNIt WATER RESOURCES CONTROL )ARD �" Y' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m -; TANK PERMIT APPLICATION INFORMATION „,. Z TANKCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 0 1 NEW PERMIT E]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED w ONE ITEM ❑2 INTERIM PERMIT E]4 AMENDED PERMIT N 11 y A / .FARM TANK-YES NO ❑ � FACILITY/SITE NAME WHERE TANK IS INSTALLED: O /� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY // �/ (� B. MANUFACTURED BY: A.LLt- A. OWNERS TANK ID R 12/ 1 i/ D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED Vff- 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ❑3 DIESEL B C. ❑ 1 UNLEADED ❑ 2 LEADED EIF MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS CHEMICAL PRODUCT ❑4 OIL HAZARDOUS ❑BO EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) T MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.WRDOUS SUBSTANCE STORED&CA.S.R III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D EOUBLE WALLED ❑3 SINGLEWALLEDWITH EXTERIOR LINER 95 UNKNOWN 99 OTHER NGLEWALLED ❑4 SECONDARYCONTAINMBiT ❑ l"ffLIIRON ❑25TAINlESS STEEL ❑3FlBERGIASS ❑ 45TEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 M ❑B 100%METHANOL COMPATIBLE FRP PONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER F1 1 RIBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PH LINING C. INTERIOR IN NG R F-15 GLASS UNING ❑6 UNUNED UNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 A ❑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 TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 95 UNKN2:N2 A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE95 UNKN N U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 R A U 91 NONE C.MATERIAL A U 5 ALUMINUM AU 6 CO A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 8 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 5 4 E ONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P B 7 PRESSURE TESTING P S 91 NONE Cr 6 5 UNKNOWN P S 99 OTHER 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 E] 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# JURISDICTION# AGENCY k FACILITY ID M TANK ID# CURRENT LOCAL AGENCY FACILI # APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 'NI'L�xC. PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ W CNE&i PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED C DATA PROCESSING COPY