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STATE OF CALIFOR4& WATER RESOURCES CONT BOARD FORM 'B': UND RGROUND STORAGE TANK PRI GRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS DT K (� ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 G01(tLO-m FAflM TANK-YES❑ N O E5N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# - B. MANUFACTURED BY: �� C. YEAR INSTALLED l/t D. TANK CAPACITY IN GALLONS: ,S Zja q�-- 11. TANK C.09TENTS 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. C. ❑ 1 UNLEADED ❑ 2 LEADED ES ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL ❑6 AVIA jBE 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D, 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 15"lALLED ❑3 SINGLE WALLED WITH DITERIOR LINER 95 UNKNOWN SYSTEM ILIXI/SI ALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 SIEEUIRON ❑1 STAINLESS STEEL ❑ 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIA ❑5 CONCRETE fi POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 2 LINI1 RUBBER UNED ❑ NG ❑3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS UNING L6ojl UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? —]YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP 02 OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN E]99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 4QV KN WN 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 N 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 91 N NE C.MATERIA A U 5 ALUMINUM A U fi CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FR A U 9 GALVANIZED STEEL A95 UNKNOW 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELE CHIC MONITOR P 8 5 GROUNDWATER MONITORIN WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 5 KNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY 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# TANK ID# 3 C) o a y 9 I/ I I G U a11, CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE �vci-E36 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# L PERMIT AMOUNT CHARGE AMT. FEE CODE RECEIPT# BY. le FORMB(fi-29-88) THIS FORM MUST BE ACCOMPANIED YAFACILITY/SREAPPLICATION, FORM 'A',UNLESSACUHRENT FORMA' HASSEENFILED DATA PROCESSING COPY