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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM tem FORM 'B': TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑B 7gNK REMOVEDoq MARK ONLY ❑ ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Ln ONE ITEM ❑ 2 INTERIM PERMIT , FARM TANK-YES❑ NO ❑ �1 l ( M4 J FACILITY/SITE NAME WHERE TANK IS INSTALLED: Fice FY FY I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SBE MANUFACTURED By A. OWNERS TANK ID N D. TANK CAPACITY IN GALLONS: 3 �+ C. YEAH INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ❑ 3 DIESEL B C. ❑ 1 UNLEADED ❑ 2 LEADED A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM El 1 PRODUCT ❑ 3 CHEMICAL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS F-14 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ D, IF NOT MOTOR N: HAZARDOUS SUBSTIANCE STORED 8 CAS.NC E FUEL,ENTER NAME OF CAS. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D ❑95 UNKNOWN ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER A TYPE OF ❑99 OTHER SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 1 STEELIIPON ❑ 25TAINLESSSTEEL El FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM El 10D%METHANOL COMPATIBLE FRP ❑ MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-1 1 RUBBER LINED ❑ 2 ALKYDLINING F-13 EPDXY LINING El4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN LINING ❑ ❑ NO ❑ 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES ❑3 VINYLWRAP El4 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑99 OTHER PROTECTION ❑ s CATHODIC PROTECTION F-191NONE ❑ p U 3 GRAVITY A U 91 NONE p U 95 UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IF pBUV2 PR DSUR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION B.CONSTRUCTION A U 1 SINGLE WALLED p U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 91 99 OTHE A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U S 10046 METHANOL COMPATIBLE FE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 9 GALVANIZED STEEL p 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 S 95 UNKNOWN P S 99 OTHER P S iVISUALGHECK P S 21NVENTORY RECONCILIATION P S 91 NONE E WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELL P S 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL' ❑YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, T. D TE IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY IDN TANK ID N COUNTYN JURISDICTION N AGENCY N E APPROVED BY NAME PHONE N WITN AREA COD CURRENT LOCAL AGENCY FACILITY 10 N G 9 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER 1 SUN RCHARGE AMT. FEE CODE RECEIPTBY. v GNECKM PERMIT AMOUNT / l FORM 6(6-29-66) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/S� P ATAPIROCESSINOGR COPY',UNLESS RRENT FORMA' HAS BEEN FILED