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STATE OF CALIFORN' WATER RESOURCES CONTF BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM #� TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH Z 10 ❑ 1 NEW PERMIT F-13 RENEWALPERMIT E]5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE �B TANK REMOVED N FACILITY/SITE NAMEWHERETANK IS INSTALLED: A 1-2- N2NU'- $ ry FARM TANK-YES❑ NO ® A CA) I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY OD A. OWNERS TANK ID# B. MANUFACTURED BY: l C. YEAR INSTALLED 4 1 V. D. TANK CAPACITY IN GALLONS: 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 B. G ❑ 1 UNLEADED K2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ®1PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER [K95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFISERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR TTy,� LINING ❑ S LINING 5 GLASS LMATERIAL COMPATIBINING �WITHL100%METiANOL?NLINED YES NO �OTHEPR- UOI ` D. CORROSION ❑ 1 POLYERILENEWRAP ❑2 TAR OR ASPHALT ❑ 3K VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Mg UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A kpl 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FOP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&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. P S I VISUAL CHECK 09 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE If 1. ESTIMATED DATE LAST USED(MONA) 2. ESTIMATEDOUANTITY 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID S TANK ID# Mj = In 10 1 223 1-91 10 10 1 (:) CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE SeT-vi 6I CN d 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT 101PIRATION DATE N CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTR BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED .;;-,TA PROCESSING COPY J