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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM FORM `B': QOTANK TANK PERMIT APPLICATION INFORMATION C MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 11 1 CHANGE OF INFORMATION ❑7 PERMANENTLYt-rNCLOSED TANK EW PERMIT ❑3 RENEWAL PERMIT B TANK REMOVED MARK ONLY ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ ONE ITEM -12 INTERIM PERMIT ' ARM TANK-YES NO 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: - S, ✓ 1 O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOSBE SPECIFY BY: A. OWNERS TANK ID NIN GALLW it D. TANK CAPACITY ONS: OD v O C.YEAR INSTALLED II. TAN CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 2 LEADED ❑3 DIESEL F A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. q GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 1 PRODUCT ❑ ❑3 CHEMICAL PROOUCT ❑4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE=FUEL, NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D A.TYPE OF ❑ DOUBLE ❑351NGLE WALLED WITH E%TEROR LINER ❑95 UNKNOWN SYSTEM �2 NGLE WALLED ❑/SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESSSTEEL ❑3 RBERGLASS ❑4 STEEL CLADWIRBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCflETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑96 UNKNOWN 111--❑---III 99 OTHER ❑ 1 RUBBEfl LINED ❑2 ALKYD LINING ❑3 EPOK1'LINING PHENOLIC UNING C. INTERIOR 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE V95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 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 C.MATERIAL A U 5 ALUMINUM6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A A U 9 GALVANIZEDSTEEL U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 7 P S S PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 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 REMAIN IN GALLONS INERT MA L? YES ❑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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY# FACILITY IDN TANK ID# 3y OO I D 8 .6101010131 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N W ITH AREA CODE 11 PERMIT NUMBER PERMIT APPROVAL LEPERMIT EXPIRATIO ATE �J CHECK PERMIT AMOUNT ,�..� SURCHARGE AMT. 6 FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPAN%..,YA FACILITY/SITE APPLICATION, FORM 'A',UNLEW%WARENT FORMA' HAS BEEN FRE NIS'