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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM ANK. � FORM B . TANK PERMIT APPLICATION INFORMATION _ 7 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T E] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑6 TEMPORARY TANK CLOSURE NK REMOVED �Q ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PER N FARM TANK-YES❑ NO a L ' cQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: c� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY UFACTUREO BY: A. OWNERS TANK ID# 390c)"01 - D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 0. MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 11. TANK CONTENTS IF(p.1),IS ❑3 DIESEL B G ❑ 1 UNLEADED E] 2 2 LEADED ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS A. E] 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ❑ 1 PRODUCT - ❑3 CHEMICALPRODUCT OIL ASTE ❑7 METHANOL �6HER(DESCRIBE IN ITEM D.BELOW) ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN D. IF NOT MOTR VEHCLE FUEL.ENTER NAME OF HAZAARDOUS SUBSTIANCE STORED&C.A.B.If �� O F I C.A.S.q: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D 5 UNKNOWN 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EMIOR LINER A.TYPE OF ❑ ❑99 OTHER SYSTEM ❑2 SINGLEWALLED ❑4 SECONDAWCONTAINMENT ❑3 FIBERGLASS ❑4 STEELCLADWIFIBERGlASS REINFORCED PLASTIC 2 STAINLESS STEEL ❑1 STEELIIRON ❑ ❑B 100%METHANOL COMPATIBLE FRP B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM MATERIAL UNKNOWN ❑99 OTHER ❑9 BRONZE ❑ 10 GALVANIZED STEEL- ❑ 1 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 PHENOUC LINING C.INTERIOR ❑5 GLASS LIMNG 6 UNLINED 95 UNKNOWN LINING ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT KNOWN ❑99 OTHER PROTECTION ❑5 CATHODIC PROTECTION []91 NONE A R 3 GRAVITY A U 91 NONE U UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AABUV2 PREOSSURE U If UNDEU 3 GRAD,BOTH IF APPLICABL A.SYSTEM TYPE A U 1 SUCTION 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 U A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NON C.MATERIAL A U 5 ALUMINUM A CONCRETE A U 9 GALVANIZEDSTEEL U 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 $ 1 VISUAL CHECK P $ 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS PIS 95EUNKNOWN TRONICMONITOR V S 99GOTTHER WATER MONITORING MON-S P $ 6 PRECISION TESTING P S 7 PRLEC ESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES 0 NO 1. ESTIMATED DATE LAST USED(MO SUBSTANCE REMAINING IN GALLONS ST OF MY KNOWLEDGE,IS TRUE AND CORRECT, THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# JURISDICTION# AGENCY# 4 rl COUNTY# = O S I O V O I O l l APPROVED BY NAME ! �I P HE WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# ' ,^ ^ /� I �� .- �a/l%I� 'vfr[�l, KK YPERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER r IPT# BY: CHECK# PERMIT AMOUNT RCHARGE AMT. FEE CO UDE r ili FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATAAPPLICATION, PROCESSINGG COP A',UNLESS A CURRENT FORMA' HAS BEEN FILED