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STATE OF CALIFOMWhLWATER RESOURCE FORM `B': SOARD U"DIGROUND STORAGE TANK TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLO WING NFORMATION FOR EACH TANK. G - MARK ONLY I NEW PERMIT _ ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT �q AMENDED PERMIT ❑ 7/E RMANENTLY 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11 51 ^�1 8 TAK NK REMOVED D L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKN ,v' ARM TANK-YES NO OWN SO rS SPECIFY '� A. OWNERS TANK ID# � C. YEAR INSTALLED B. MANUFACTURED BYE II. TANK CONTENTSD TANK CAPACITY IN GALLONS: IF(AO� 1 .1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ETROLEUM B 3 CHEMICAL PRODUCT 4 OIL C. ❑ I UNLEADED E 2 LEADED E] 3 DIESEL 0 5 HAZARDOUS Ej 95 UNKNOWN Q RODUCT 04 GASAHOL 0 5 J FUEL 6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL80 EMPTY,ENTER NAME OF Eo 2 WASTE ❑ 7 METHANOL HAZARDOUS SUBSTANCE STORED 8 C.A.S.# 99 OTHER(DESCRIBE IN ITEM D,BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C, A. TYPE OF L_I DOUBLE WALLED 0 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 2 SINGLE WALLED 11 4 SECONDARY CONTAINMENT ❑ 95 UNKNOWN 99 OTHER MATERIAL E] 5 CONCRETE B. TANK I ONCRE-N El 2 STAINLESS STEEL 0 3 F18ERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC El 6 POLYVINYL CHLORIDE 7 ALUMINUM 9 BRONZE r110 GALVANIZE-STEEL ❑8100%METHANOL COMPATIBLE FRP 95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER lINEO 0 2 ALKYD LINING LINING El5 GLASS LINING El ❑6 UNLINED 3 EPDXYUNING 11 4 HENOLIC LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' 95 UNKNOWN YES NO 99 OTHER D. CORROSION 1 POLYETHLENE WRAP PROTECTION ❑2 Tae OR ASPHALT E13 L WRAP 5 CATHODIC PROTECTION ❑4 FIBERGLASS REINFORCED PLASTIC 91 NONE 95 UNKNOWN HER IV- PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,B❑OTN F99 TAPPLICABLE A. SYSTEM TYPE A U I sUUIION B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN q U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A A U 91 NONE %U 5 UNKNOWN A C. MATERIAL A U 5 ALUMINUM U 3 POLYVINYL CHLORIDE PVC A U 99 OTHER A fi CONCRETE ( ) U 4 FIBERGLASS PIPE A U 91 NONE A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 99 OTHER I V S I DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P g 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 9 NNONE P 8 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S 99 OTHER 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3 WAS TANK FILLED WITH LONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,qND TO THE BEST LOF MV KNOWLEDGE,MATERIAL' O S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# CURRENT LOCAL AGENCY FACILITY IO# / V (/ G PERMIT NUMBER L APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE J CNECKM PERMIT AMOUNT SURCHARGE RMT. FEE CODE RECEIPT# FORM R(6-29-88) THIS FORM MUST BE ACCOMPANI B A FACILITY/SITE APPLICATION, FORM `A',UNLESS A C RgENT FORMA' HAS BEEN FILED 11 11 imilimO-l .€f DATA PROCESSING COPY