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STATE OF CALIFORNIA* WATER RESOURCES CONTROLORD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONo COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. MARK ;' Y;;;A PERMIT ❑3 RENEWAL PERMIT ONE I 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 RIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED� 2FACILITY/ NK IS INSTALLED: L 1� C- fble.l� JL1 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— c FARM TANK-YES❑ NO � SO SPECIFY O A. OWNEgS TANK ID a B. MANUFACTUREDBY: C. YEAR INSTALLED � D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.i),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. O RHAZARDOUS MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ CHEMICAL PRODUCT ❑ 4 OIL 1 UNLEADED ❑2 LEADED ❑3 DIESEL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 ET FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN 2 WAST7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) MOTOR VEHICLE FUEL,ENTER NAME OF SUBSTANCE STORED 8 C.A.S.a �� 01 I 1'I1e 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&1) CA S.#: [A. PE OF ❑ I OOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER STEM ❑2 SINGLE WALLED ❑ 4 SECONDAM CONTAINMENT 95 UNKNOWN 99 OTHERNK ❑ 1 STEELIIgON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC TERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 81W%MEFHANOL COMPATIBLE FRP 9 BRONZE ❑ ❑ ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ q PHENOLIC LINING LINING [:15 GLASS LINING ❑6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEFHANOL? YES ❑ 95 UNKNOWN ❑ ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEFHLENEWMP ❑2 TARORASPHALT ❑3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE ❑ q FIBERGLASS REINFORCED PLASTIC El95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A u 1 sucnoN A u z PRlSs A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A LA I 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 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP 9 A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PpIAAARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P g 4 ELECTRONIC MONITOR P g 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LA ST USED(MO/YR) 2 ESTIMATED CC , 11 11 OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS NERT 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 ID# TANK ID# � Zz3 CURRENT LOCAL AGENCY FACILITY ID# / ?S pj APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEgMIT EXPIflATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE flECEIPT# BY: C�f FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FIE /�/ DATA PROCESSING COPY