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a l A l E OF CALIFOR, FORM `B': 1NATER RESOURCES CONT PRI30ARD UNDERGROUND STORAGE TANK RAM a' S�-f T/Q►NC TANK PEAPPLICATIONt COMPLETE RSEPARATE RFMITWITH � INWING FOM RATION °��+{ MARK ONLY i NEWPERMI7 ION FOR EACH TAN ONE ITEM ❑3 RENEWAL PERMIT u 1:72 INTERI11 M P 11 ERMIT 4 AMENDED PERMIT 5 GRANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPORARY TANK CLOSURE 11,11 EVTANK REMOVED 1. TANK DESCRIPTION 19 COMPLETE ALL!TENS-IF UNKNOWN FARM TAM(.YES NO A. OWNERS TANK ID# �� SO SPECIFY Jtth C. YEAR INSTALLED B, ,MANUFACTURED BY: y ll. TANK CONTENTS V D TANK CAPACITY IN GALLONS: rV, IF(A•1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM ❑3 CHEMICAL PRODUCT 4 OIL B 1 UNLEADED El2 LEADED 0 3 DIESEL 5 HAZARDOUS ❑ � PRODUCT 0 4 GRSAHOL 90 EMPTY ❑95 UNKNOWN ��77 5 JET FUEL ❑6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF L_J 2 WASTE 7 METHANOL HAZARDOUS SUBSTANCE STORED&C,A S # / 9 OTHER DESCRIBE IN ITEM D.BELOW) III. TANK CONSTRUCTION MARK ONE ITEM 74 C'A'S'#: 11 11 ONLY IN BOX A,B,C,g D a A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM �SINGLEWALLED � 95 UNKNOWN �,� 99 OTHER 4 SECONDARY CONTAINMENT Ej LJ " STEEUIRON ❑2 STAINLESSSTEEL B. TANK 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP F-19 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYDUNAG ❑3 EPDXYUNING ❑ 4 PHENOLIC LINING F-15 GLASS UNING �6 UNLINED ❑ IS LINING MATERIA!COMPATIBLE WP7H 100960❑95 UNKNOWN YES ❑NO E�4iy OTHER D. CORROSION I POLYE"HLENE WRAP ❑2 TAR OA ASPHALT ❑ 3 VINYL WRAP PROTECTION 5 CATHODIC PROTECTION ❑91 NONE (r95 UNKNOWN ❑4 FIBERGLASS REINFORCED PLASTIC �I 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A 1 SINGLE WALLED A U A U 3 GHAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 2 DOUBLE WALLED A U 3 LINED TRENCH A A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)1 NONE U 4AFI EHGLASS P PE A AU U919NONE ER C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A A U 9 STEEL CLAD W1 FRP A 5 UNKNOWN A U 99 OTHER U 9 100%METHANOL COMPATIBLE FRP -V� LEAK DETECTION SYSTEM CRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION CIRCLED, P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 8 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S 99 OTHER 1. ESTIMATED DATE ST USED(MO/YR) � J � 2 ESTIMATED QUANTITY OF �/ SUBSTANCEEiEIII I INC IN 3. WAS TANK FI ED WITH THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 7-"z'BEST OF MY KNOWLEDGE, IS TRUE AND ❑ NO APPLICANT'S NAME(PRINTED 8,SIGNATUAEj CORRECT. DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# UE] FACILITY ID# TANK ID# zoo CURRENT LOCAL AGENCY FACILITY ID# i APPROVED BY NAM / PHONE N WITH AREA CODE PERMIT NUMBER l/ PERMIT APPROVAL DATE FERMI EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEu A FACILITYISITE APPLICATION, FORM `A',UNLESS A G HRENT FORIN'A' HAS BEEN FILES} DATA PROCESSING COPY