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moo.. STATE OF CALIFORNI WATER RESOURCES CONTR 90ARD u � FORM `B': UNDERGROUND STORAGE TANK PROGRAM A o TANK PERMIT APPLICATION FORMATION opu.P TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. _ 1 � ❑ RMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY 1 NEW PE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FARM TANK-YES NO ❑ �' FACILITY/SITE NAME WHERE TANK IS INSTALLED: 8/_5 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: EC. YEAR NERS TANK ID# INSTALLED U D. TANK CAPACITY IN GALLONS: /I OO .7 Z II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. [:] 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL FD. ❑7CHEMICAL OR VEHICLE FUEL ❑ 2 PETROLEUM ❑ PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 80 EMPTY �5 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ ARDOUS ❑ ❑ 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,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7.AL MINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 95PHENONOWN LINING LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ PROTECTION F-] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE BNo E A U 95 UNKNOWN A U 99 OTHER A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1004b METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR $ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 91VNONEE WELLS P S 95EUNKNOWN LECTRONIC MONITOR P S 99GOTTHER ROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 7 LL141oj ��77771 E=APPROVED BY NAME WITH AREA CODE CURRENT CAL AGENCY FACILITY ID# K7 PERMIT APPRO AL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM `A',UNLESS RENT FORMA' HAS BEEN FILED FORM 6(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITY/DSIA A PROCESSING NG COPY