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STATE OF CALIFORNIA WATER RESOURCESCONTRC' 90ARD FORM `B': UND�WGROUND STORAGE TANK PRO%d'RAM �q TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGEOFINFORMATION ❑7 PERMANENTLY K 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE _ j 2,0 �, (- FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: IV ' w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID N B. MANUFACTURED BY: 1 to C YEAR INSTALLED [,(N6/Jl./ D. TANK CAPACITY IN GALLONS: 2 D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC. ❑ 1 UNLEADED 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT E]4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL [—]6 AVIATION GAS E]5 HAZARDOUS [—]80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF F-1 VDOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL WD W/FlBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERUNED ❑2.bWDLINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C LININGR ❑5 GLASS LINING 6 UNLINED ❑95 NKNOWN INTERIO [—] LS LINING MATERIAL COMPATIBLE WITH 0%METHANOL? E]YES ❑ NO �THER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT [—] WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFA13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTIONU 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(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEELCLADW/FAP A U 810096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 5 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. `19) P S IVISUALCHECK P S 2 INVENTORY RECONCILIATION 3VADOSE WELLS P B 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS (V P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATEDD LAST USED(MO/YR) 2.ESTIM ED QUANTITY OF lWASTANNIFILLEDWITH S BS NCE REMAINING IN GALLONS INE IAL? [—]YES [:3 NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# ffElI as X63 1 1 0o0 CURRENT LOCAL AGENCY FACILITY ID# APPROVEDBY PHONE#WITH AREA CODE � 6 -z ;fl-c—/ PERMIT NUMBER PERMIT APPROVAL DATE PtAMIT EXPIRATION D CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE I A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT fOMBEEN FILED DATA PROCESSING COPY