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STATE OF CALIFORNIA WATER RESOURCES CONTROL >JARD "' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM o K PERMIT APPLICATION INF (aTANK. Z TANK COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR H 90 ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑g TANK REMOVED MARK ONLY ❑ ❑y AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE (,.t) ONE ITEM ❑2 INTERIM PERMIT _ FARM TANK-YES Im ❑ N l3 8-/ c_, o FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FY I. TANK DESCRIPTION COMPLETE ALLITEMS-IF UNKNOWN—SO SB MANUFACTURED BY: A. OWNERS TANK 10# 1L D. TANK CAPACITY IN GALLONS: C.YEARINSTALLEO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A 1),IS TMC. DD COMPLETE ITEM D. LEADED ❑3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM H 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT ❑4 OIL 7 METHANOL 5 HAZARDOUS ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ ❑ 00 EMPTY 95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / C.A.S.W WV� HAZARDOUS SUBSTANCE STORED 6 C.A.S.# W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D 95 UNKNOWN A.TYPE OF F-1i DOUBLE WALLED ❑ 3 SINGLE WALLED WITH Do EMOR LINER SYSTEM ❑2 SINGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑I STEELIINON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/RSEMLASS REINFORCED PLASTIC B.TANK �5 CDNCRETE ❑6 POLYVINYLCHLORIDE ❑T A ❑B 1W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑W OTHER ❑ I RUBBFRUNED ❑2 ALKYDUNING ❑ 3 EPDXY UNING 4 UC LINING C.INTERIOR ❑ 5 GLASS LINING ❑6 UNUNED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES 0N 99 OTHER D.CORROSION ❑ 1 PoLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 I'll I P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION [-]91 NONE UNKNOWN 99 OTHER PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE �. A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U U 99 OTHER A SYSTEM TYPE NCH A U 91 NONE A 95 UNKNOWN U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGL THANOSSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL U UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P B 91 NONEC--P-9-95 U KNO P S 99 OTHER 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 INERT MATERIAL? [1]YES ENO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE .00AL AGENCY USE ONLY P JURISDICTION# f AGENCY# FACILITY ID# TANK ID# � = l 10101 0 AGE F ATIT'Y IO# APPROVED BY NAME PHONE P WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: C B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY