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STATE OF CALIFORNI/ WATER RESOURCES CONTRO' 'lOARD �I FORM `B': UNDEFTGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m� .... COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 N5W PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ! INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: n FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# J B. MANUFACTURED BY: v C. YEAR INSTALLED C D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITECA) M D. A. 0 R VEHICLE FUEL ❑ 2�PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-]3 CHEMICAL MA PRODUCT IL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN EZ21TASfE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF KJ HAZARDOUS SUBSTANCE STORED 8,CAS.# - l� r AXs*- x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �PSIRGLEWALIED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EDXS BUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC L TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORDE ❑7 ALUMINUM ❑81009E METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS UNING E�4*DRUNED ❑95 UNKNOWN ❑ IS UMNG MATERIAL OOMPATIBLE WITH 10094 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E�J�E ❑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 to GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW7FRP A U B 100%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 SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. Jy P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS ZV•F� P 4St PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 GALLONS SUBSTANCE REMAINING IN 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID R 16161 / vo CURRENTLOCAL AGENCY FACILITY ID# APPR ED BYNAMExN PH NE N WITH AREA CODE V/ _'/ V PERMIT NUMBER PER AP p�OViAL AA PERMIT EXPIRA ON DAfE �2 QQ I CHECKN PERMIT AMOUNT SURCHARGEA T. FEE CODE RECEIPT BY: FORM B(3-7-SB) THIS FORM MUST BE ACCOMPANIEu HY A FACILITY/SITE APPLICATION, FORM'A',UNLESSRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY