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t OF CALIFORNI WATER RESOURCES CONTROI L30ARD FORM B : UN GROUND STORAGE TANK PR09AM TANK TANK PERMIT AFr-LICATION INFORMATION COM LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ON;ITEM RK NL;NAME 1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGEOFINFORMATION❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑ 7PERMANENTLY CLOSED T K ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITE WHERE TANK IS INSTALLED: I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— �g(�y FARM TANK-YES NO ❑ SO SPECIFY ; O A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. RHAZARDOUS; MOTOR CHEMICAL PRODUCT ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL CHEMICAL PRODUCT ❑ 6 OIL 00 ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW)MOTOR VEHICLE FUEL.ENTER NAME OF SUBSTANCE STORED S,C.A.S.N C.A.S.N: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOIL A,B,C,A D A TYPE OF ❑ I UOUBLL WALLED 3 SINGLE WALLED WITH EF-01OR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 8.TANK 1:11 E] TEEL ST®-1 RON 2 STAINLESSS ❑3 RSERGLASS ❑ 4 STEEL CLAD W/PBERGUSS RENFORCB)PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZE)STEEL ❑95 UNKNOWN ❑ss OTHER C. INTERIOR ElI RUBBER UNED 2 UMUNING 3 EPDXY LINING ❑4 PHENOLIC LINING ❑ LINING ❑6 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES []No 99 OTHER ------------- D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLAS,'.0 PROTECTION ❑6 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER W. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE ww A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 'V 8. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN C.MATERIAL A U I STEEL/IRON A U BB OTHER 1V A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U a FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER A U 8 100%METHANOL COMPATIBLE FRP n\ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCIUA I FUN P 3 3VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VRI 2. ESTIMATED QUANTITY Of SUBSTANCE REMAINING IN 3 WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑WEB ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY p mFACILITY IDN TANK IDN 1= CUP NT LOCAL AGENCY FACILITY 10 4 APPROVED BY NAME PHONE N WITH AREA CODE `11 PERMIT NUMBER PER IT APP OVAL DATE PERMIT EXPIRATION DATE \L/ CHECKkPERMIT AMOUNT /& F�i v SURCHARGEAMT. FEE CODE RECEIPTN BY: FORM a(3-7-88) THIS FORM MUST BE ACCOMPANIED efA FACILITY/SITE APPUCATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED DATA PROCESSING COP`!