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STATE OF CALIFORN* WATER RESOURCES CONTRI&OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �. G COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 7 PERMANENTLYC ANK ONE ITEM F-121NTERIMPERMIT 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVE (�' Y Oft q C11 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 24 OC.I g MTANK-YES❑ NO N N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE IFV FV A. OWNERS TANK ID# B. MANUFACTURED BY: Uv A' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK96NTENTS 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 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,/6 D HAZARDOUS SUBSTANCE STORED 8 C.A.S.# Vo - C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 A.TYPE OF ❑ i BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER L211 STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 810096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING FNKNOWN ENOLIC UNING LINING ❑5 GLASS UNING [-]6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NOTHER D. CORROSION ❑ 1 POLYETHLENEWflAP ❑2TAR OR ASPHALT ❑VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 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 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL UI 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. NS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE 8 PS UNKNOWN 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# = = I ol oI c* r CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE —30-9 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BVy�/O Ili RMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN F/ILNED/�, 4 4 DATA PROCESSING COPY