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s STATE OF CALIFOR► WATER RESOURCES CONT BOARD PR�GRAM u�\ FORM `B': UNDERGROUND STORAGE TANK Q TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING llNf ORMATION FOR EACH TANK. ❑ 3 RENEWAL PERMIT �HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY 1-11 NEW PERMIT E 4 AMENDED PERMIT j� 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDE— FACILITY/SITE ONE: ITEM 1-12 INTERIM PERMIT ❑ u FARM TANK -YES ❑ NO NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID It �-- B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. B C. [:] 1 UNLEADED E] 2 LEADED ❑ 3 DIESEL A. F-11 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY 5 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF C.A.S. HAZARDOUS SUBSTANCE STORED & C.A.S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 6 D ❑ 1 D BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WMBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING rjgUNKNOWN C. INTERIOR[—]F-16 � GLASS LINING UNLINED LINING IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ i POLYETHLENEWRAP F� 2 TAR ORASPHALT � 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEUNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 91 NONE A 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 3 POLYVINYL CHLORIDE (PWC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 1 STEEUIRON A U 2 STAINLESS STEEL A A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 10096 METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A 05 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P WELLS P S 4 ELECTRONIC MONITOR P S 5 GHOUNU vvµ i cn MUn P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P�3 9` 1jONE � -e rc Yb-AUNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED (MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL? YES NO GALLONS THIS FOAM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME (PRINTED & SIGNATURE) CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # LL —1 ( 0;;= FoLd24 APPROVED Y NAME PHONE # WITH AREA CODE CURRENT LOCAL AGENCY FACIIATY ID k v i p , ,} / Pq f721— PERMIT NUMBER PERMIT APPROVAL DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE EXPIRATION DATE RECEIPT # 1 BY: FORM 6 (6-29-86) THIS FORM MUST BE ACCOMPANIE A FACILITY/OA APPROCESS NORM 'A', UNLESS AZTRENT FORMA' HAS BEEN FILED 0