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STATE OF CALIFORN' WATER RESOURCES CONTE BOARD "'"" FORM 'B': / UNDERGROUND STORAGE TANK PROGRAM :' t/ TANK PERMIT APPLICATION INFORMATION y� �� T^• COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 012 ENTLY CLOS K ONE ITEM ❑2 INTERIM PERMIT ❑6 AMENDED PERMIT ❑6__TEMPORARY TANK CLOSURE S TANK REMOVE O W FACILITY/SITE NAME WHERE TANK IS INSTALLED: S� //W 14S r7 ZWRIATANK-YESO NO 2r I N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: 07t CD C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: x 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.Ih IS NOT MARKED,COMPLETE ITEM D A. Eyl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ I UNLEADED1�1 2 LEADED L] 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑1 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ M 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 6.C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WANED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEELIRON ❑2 STAINLESS STEEL ❑3 FIBERGUIM ❑/STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 10D%METHANOL COMPATIBLE FRP MATERIAL. . ❑9 BRONZE ❑ IB GALVAN2ED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIBBER UNED ❑ 2 MOD LINING ❑ 3 EPDXY LINING ❑ /PHENOLIC LINING LINING ❑5 GLSSUNNG ❑6 LWUNED ❑ 95 UNKNOWN ❑IS UNM MATERAL COMPATIBLE WITH 100%METWIOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWR&P ❑2 TARORASWMLT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U B 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. t 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P t 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P t e PRECISION TESTING P t 1 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED LATE LAST USED(MO/YFI) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONt INERT MATERIAL? ElYES ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION t AGENCY N FACILITY ID N TANK ID N ® ❑� 1 14 U 1 5 6 & S CURRENT LOCAL AOENCY FANCCIL^IITY ID N r APPROVED BY NAME PHONE I WITH AREA CODE / -1 J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE U p— CHECK N PERMIT AMOUNT SURCHARGE AMT. I FEE CODE RECEIPT F BY: A /j EoRM B(B-2B.ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' MAS BEEN FILED