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STATE OF CALIFORho WATER RESOURCES CONTS BOARD FORM 'B': UNDERGROUND STORAGE TANK PRRAM � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. ®_ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION fACLOSrN10 ONE ITEM ❑2 INTERIM PERMIT ❑ 7 PERMA❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REFACILITY/SITE NAME WHERE TANK IS INSTALLED: (� Si^ N FApM TANK- I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (AD A. OWNERS TANK ID# ' B. MANUFACTURED BY: C. YEAR INSTALLED u r/ D. TANK CAPACITY IN GALLONS: Q II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LDNOT OR VEHICLE FUEL ❑2 PETROLEUM B. / C. ❑ 1 UNLEADED LEADED 3 DIESEL MICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) TOR VEHICLE FUEL,ENTER NAME OF S SUBSTANCE STORED&C A.S.# C.A.S.p: III. TANK CONSTRYCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF Z 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 6 POLYVINYL CHLORIDE 7 LUMINUM MATERIAL SCONCRETE ❑ ❑ ❑8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING 4 P OUC LINING LINING ❑5 GLASS LINING E] ❑6 UNLINED 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 PKWAAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑gg OTHER IV. PIPING INFORMA ON 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 91 NONE A U 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A�'� L�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZEDSTEEL Akt..) UNKNOWN A U 8100%METHANOL COMPATIBLE FRP l) A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S 6 PRECISIONTESTI S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM 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 COUNTY# JURISDICTION# AGENCY# FACILITY 10# TANK ID# o () a o CURRENT LOCAL A NCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE P"MIT NUMBER PER MITAPPROVAL DATE PERMIT EX/P) Z IR IN DATE CHECK# PERMIT AMOUNT SURCHApGE AMT. FEE CODE j'v p 'E1PTXr 1 BY: '1 FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIOTY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY