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STATE OFCALIFORNIA4^ WATER RESOURCES CONTROL LARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ° TANK PERMIT APPLICATION INFORMATION TANK "" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Q [FACILITY/SITE ARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TA NE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT. 6 TEMPORARY TANK CLOSURE TANK REMOVEDFa8T ANK-YES NO ❑ IV NAME WHERE TANK IS INSTALLED: 3 7 d v 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: / D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED / IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKEO,COMPLETE ITEM D. A. F-11 MOTOR VEHICLE FUEL F-] 2 PETROLEUM 8. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1'PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HA7ARDOUS ❑ BO EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER{DESCRIBE IN ITEM D,BELOW) D. 1F NOT MOTOR VEHICLE FUEL,ENTER NAME OF t � C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# k Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D E A.TYPE OF ❑ 1 DOUBLE WALLED 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 WlFIBERG ASSREINFOACEDPLASTIC S.TANK ❑ 5 CONCRETE. ❑6 POLYVINYLCHLORIDE [:]V95 UM ❑B t00%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEELOWN ❑ 99 OTHER ❑ 1 RUBBER LINEO ❑2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 P OLIC LINING C. INTERIOR F-15 GLASS LINING F-] 6 UNLINED UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER D.coRRosraN ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT FlKlNYLWRAP ❑ 4 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 r A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY .I 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 U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLADW/FRP A U B 100%METHANOL COMPATIBLE FRP t A U 9 GALVANIZED STEEL A U 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. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P ELECTRONIC MONITOR P 5 5 GROUND WATER MONITOR$NG WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P $ 91 NONE S 'UNKNOWN P S 99 OTHER l VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE r 'F 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN �} INERT MATERIAL? ❑YES E] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME{PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY 10# TANK ID# EI I 101Dr / 7110101 � l q] CURRENT LOCAL AGE F TY IDN APPROVED BY NAME PHONE 0 WITH AREA CODE G�4 30 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rl CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE �� RECEIPT# BY: � FORM B(6-29-Ba) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM`A' HAS BEEN FILED DATA,PROCESSSING COPY