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WATER RESOURCES CONTROL L�\RD STATE OF CALIFORNIA UNDERGROUND STORAGE TANK PROGRAM Z FORM 'B': TANK PERMIT APPLICATION INFORMATION Lc TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EA 10 CLOSED TANK ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION B TANK REMOVED /,Sly MARK ONLY ❑1 NEW PERMIT 6 TEMPORARY TANK CLOSURE ❑ 1 CAS 2INTERIM PERMIT ❑4AMENDED PERMIT ❑ FARM TA14K-YES NO ❑ 00 ONE ITEM ❑ 00 FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. CIFY TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN So Se I MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MARKED,COMPLETE ITEM PLEADED ❑3 DIESEL II. TANK CONTENTS e C. ❑ 1 UNLEADeo ❑6 AVIATION GAS ❑2 PETROLEUM A. [D 1 MO TOR VEHICLE FUEL ❑1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑3 CHEMICAL PRODUCT ID4 OIL 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ C.A.S.k: R VEHICLE FUEL,ENTER NAME D HAZARDOUS SU STANCE STORED&C.A.S.#OF III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8.C,■D ❑95 UNKNOWN A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIORLINER SYSTEM ❑2 SINGLE WAILED 114 SECONDARY CONTAINMENT 99 OTHER STEEL AD ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 100%M METHANOL COMPATIBLE PLASTIC 0.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1W%METHANOL COMPATIBLE FAP MATERS ❑9 BRONZE ❑10 GALVANIZED STEEL ❑M UNKNOWN ❑99 OTHER ❑1 RUBBER UNFD ❑2 ALKYD UNING ❑3 EPDXYLINING ❑4 PHENOUCUNING C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN LINING ❑IS UNING MATERIAL COMPATIBLE WITH 10091 METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑1 POLYETHLBIEWRAP ❑2TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 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 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PI A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 810D%METHANOLCOMPATISLEFRP A U 9 GALVANIZED STEEL A U 95 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 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER V1. 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 [:] 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 A�UNTY# JURISDICTION# AGENCY# FACILITY IDN TANK ID N L M = 77M loO CURRENT LOCAL AGENCY FACILI D N "DAPERMIT VIED PHONE N WTT11 AREA CODE EG PERMIT NUMBER PERMIT APPROVAL EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE ANT. RECEIPT FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY