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OFF�w STATE OF CALIFORN19 WATER RESOURCES CONTROOARO FORM 'B': UNDERGROUND STORAGE TANK PROGRAM mo TANK TANK PERMIT APPLICATION INFORMATION ` a COMPLETE A SEPARATE FORM WITH THE FOLLOWIPPG INFORMATION FOR EACH TANK. MARK ONL ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 TCHANGEEMPORARY R INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED cn FARM TANK-YES❑ NO ❑ 1'V FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 007 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 to A. OWNERS TAIJK ID# B. MANUFACTURED BY: o D. TANK CAPACITY IN GALLONS: Q Vq- C.YEAR INSTALLED 11. TANK COP TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKC. ED,COMPLETE ITE D. LEADED 3 DIESEL A. 1 MOT RVEHICLEFUEL ❑ 2 PETROLEUM ,,,,8�. L.J 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 3 CHEZ ICAL PRODUCT ❑4 OIL ❑ 5 HAL FOCUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MO OR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOU5 SUBSTANCE STORED&C.A.S.# Ill. TANK CO STRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑I OOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑2 ALKYO UNING ❑3 EPDXY LINING ❑4 P NOUC LINING C. INTERIOR 5 GLASS LINING F-16 UNLINED 95 UNKNOWN LINING I ❑ ISLINING MATERIAL COMPATIBLEWIT 1089h METHANOL? ❑YES [:]NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTI N ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM"N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TY E U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 5 UNKNOWN A U 99 OTHER B.CONSTRU TION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL. A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FOP A U 9 GALVANIZED STEEL P95 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. 07�C P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES NO GALLONS THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY# JURISDICTION# AGE 7 6 = APPROVED BY NAME PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDN n ' N PERMIT NUMBER PERMIT APPROVAL DATE PE MIT PIRATION DATE CXECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN 9Yo FORM B(6-29- ) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SDITE ATAPPR TION, OORM' ''UNLESS A CURRENT FORMA' HAS BEEN FILED