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.. i i L#'1A�o.�tyrJYJ."cyMKAA. CI.'w!np•�.11y�i��... _ STATE OF CALIFORN18 WATER RESOURCES CONTR*OARD "•� FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK COMPLETE A SEPARATE TANK PERMIT APPLICATION INFORMATION RATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANKREMOVED /S' ' FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 N4=� IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) A. OWNERS TANK IDN B. MANUFACTURED BY: cn C.YEAR INSTALLED g'Q D. TANK CAPACITY IN GALLONS: 0067 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUELT��I•2 PETROLEUM B G. ❑ 1 UNLEADED E]2 LEADED ❑3 DIESEL MICAL ❑ 3 CHEPRODUCT LJ 4 OIL d PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.M HAZARDOUS SUBSTANCE STORED&C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑ 287TAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPDXY LININGHENOLIC UNING C. INTERIOR LINING F-] 5 GLASSUNING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP 2TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 'U,/I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE 5 UNKNOWN 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 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE A 7U)95 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. A P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Y P 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V '.- INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES E] NO THISF M 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 CCOOU�NTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL-T"GENCY FACILITY � � APPROVED BY NAME � � PHONE M WITH AREA OCODE 2-1/40 PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECSIFT# BY: G IL FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/DATAPPR TION, NOGR' 'UNLESS A CURRENT FORMA' HAS BEEN FILED