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STATE OF CALIFORNI WATER RESOURCES CONTRC `BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ® COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5K CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1137 FACILITY/SITE NAME WHERE TANK IS INSTALLED: !� FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N W i A. OWNERS TANK ID# R. MANUFACTURED BY: 1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CgNTENTS 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 DIESEL F-13 CHEMICAL PRODUCT ❑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&CAS.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER E]95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON25TAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 810DR METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 0 GALVANIZm STEEL ❑95 UNKNOWN ❑ N OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 LINING ❑3 EPDXY LINING F-14 PHENOLIC UNING LINING F-]5 GLASS LINING ❑6 UNLINE ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1"M L? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEDLENEWRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP Ll4 FIBERGLASS REINFORCED PLAS IC { PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U I NDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 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 N 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U XPOLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U7 TEELCLADW/FRP A U 81 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4EL TRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED DUANTRYOF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# '� = = 16161115-1JS o CURRENT LOCAL A CYfACILI IDN APPROVED BY NAME y� PHONE N WITH AREA CODE v a I PERMITNUMBER PE RMITAPPROVALOATE PE IT EXPIRATION DATE CHECK N PERMIT AMOUNT I SURCHARGE AMT. FEE CODE I RECEIPT N BY: J5 FORM D(6-29-99) THIS FORM MUST BE ACCOMPAMEU BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS.+.ARRENT FORMA HAS BEEN FILED LATA PROCESSING COPY