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WATER RESOURCES C STATE OF CALIFORONT qM BOARD FORM 'B': UND RGROUND STORAGE TANK PROGRAMam , 1 TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ E OF INFORMATION � 7 P NTLY CLOSED MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE ONE ITEM ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE B TANK REMOVED ❑ 2 INTERIM PERMIT C O� FARM TANK-YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: J 1. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY Q �\ I B. MANUFACTURED BY'. u A. OWNERS TANK IDN ��1 v � ) a` D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED Cit LD`� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MCRKE❑D COMPLETE ITEM UNLEADED EADED ❑ 3 DIESEL B. A. 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS 1 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL NOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) F-1 5 HAZARDOUS ❑ BO EMPTY E] 95 UNKNOWN ElZ METHA 2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.q: HAZARDOUS SUBSTANCE STORED&C A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D ❑95 UNKNOWN 1 DOUBLE WALLED 3 SINGLE WALLED WITH DQERIOR LINER A.TYPE OF F-1 ❑ 99 OTHER SYSTEM SINGLEWALLED E]4 SECONDARY CONTAINMENT 1 STEELIIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑Z ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ i RUBBERLINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIORLINEO El 95 UNKNOWN k _ LINING — E] 5 CUSS LINING❑ El ❑ ggOTHER -( ISLINING MATERIAL COMPATIBLE WITH 100%MEfHANOL? YES NO � 3VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC 0. CORROSION F-] 1 POLYEfHLENE WRAP ❑2 TAR OR ASPHALT El 99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE -950NKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLENONE A11, i21 9 UNKNOWN A U 99 OTHER A U 2 PRESSURE A U 3 GRAVITY_A SYSTEM TYPE A U 1 SUCTION 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 A U iSTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4FIBERGLASS g 100%METHANOL-0OA UIB91 FEE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 99STEEL OTHER�D W/FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V. LEAK DETECTION SYSTEM P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 9B UNKNOWN MONITOR PS LECTRONIC P S 9G9OTHER WATER MONITORING WELLS P 5 6 PRECISION TESTING P S ] PRESSURE TESTING p S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, DGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE? LOCAL AGENCY USE ONLY TANK ID N FACILITY ID N r UNTY# JURISDAGE I U `IAPPROyED BY NE PHONE N WITH AREADELOCAL AGENCY FI�GILITY IDN /I / I IYUMBER U I` PERMITAPPROVALDATEII ,�// PERMIT EXPIRATION DATE 000 UUU NECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE EIPTN BY: FQRM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY