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STATE'OF CALIF'ORN WATER RESOURCES CONT • OARD FORM 'B': UND GROUND STORAGE TANK PR RAM e 'P- TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PEEMANENTLY CL 1 C ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT © 6 TEMPORARY TANK CLOSURETANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED. -�S'/ �' ❑ NO 117 —........... .-. NI 14& �` =TANK-YE$ 4MII 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CQ A.,OWNERS TANK IDN _ B. MANUFACTURED BY' (f GTI C. YEAR INSTALLED L 0. TANK FAPACIT'IN GALLON$:/614 Q 11. TANK PONTENTS IF(AA),M MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED.COMPLETE ITEM D. A ff1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 7 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0•BELOW} O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SURSTANCF ST(AFnA C AS # Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF ❑ iRMINUWALLED © 9 51NOLE WALLED WII H UILHIUH LINER ❑9$UNKNOWN SYSTEM '2 SINGLE WALLED ❑4 SECONDA WNTAINMENT 99 OTHER B.TANK 1 OTLSLARON ©2STNSB NI-m 5TEU ❑$Emu-i 4 STEEL CUD WIEIBERGLA$S REINFORCED PLASTIC 5 CONCRETE MATERIAL ❑ ❑8 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8Ip0A METHANOL COMPATIBLERTP ❑9 BRONZB n 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHFR ._ C. INTERIOR ❑ 1 RUBSERUNED ❑2 ALKYD UNING ❑3 EPDXYLINING ❑HEOLIC LINING LINING ❑ 5 GLASS UNING E-16 UNUN� UNKNOWN ❑ 16 UNING MATERAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑NO ❑ 59 oma D.CORROSION ❑'1 POLYETHLQff WRAP ❑2 TM OR ASPHALT ED 9 LWRAP ❑A RRERGUSSREIN yp�,US7C PROTECTION ❑.5 CATHODIC PROTECTION ❑9I NONE 96 UNKNOWN ❑99 0THER ��""' IV. PIPING INFORMATION CIRCA A IF ABOVE GROUND, U IF UNDERCnouND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTIONA U. 2 PRESSURE A U 3 GRAVITY A U 91 NONE 95 UNKNOWN A u gg OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U S LINED TRENCH _A U 91 NONE A V 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 9TAINUE$S STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FI C.MATERIAL A U 5 ALUMINUM A CONICRt7EBEROlAS3 PIPE A U g1 NONE ' A U 7 STEEL CLAD WIFRP A U g 10 ERGLA'HRNOL COMPATIBLE91 NP Y A U 9 ORLVANIZEp STEEL UF UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK A $ v w+1ENTDM AaCONC1unTION P S YADose wEl.1.5 r u a tLtCTIioNIC MONITOR p 8 5 GROUND WATEq MONITORING WELLS f J` P $ B PRECISION TESTING P S 7 PgESSURETE811NG A $ i NONE P 8 95 UNKNOWN P S 99 OTHER yI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DRTE UST UBED(MOYYR) 2. ESTIMATEDg�UE SSTIMA NCE s. WAS TANK FILLEq WRH GALLONS INERT MATERIAL? ❑YES ❑ NO TMlS FOflM HHS ULLN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANA CORRECT. =APPLICANTS NAME(PRINTELA SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION S AGENCY B FACILITY ID B TANK ID M CURRENT 44CAL AGENCY FACILITY 10 a . APPROVED BY NAME �PHONEI,r w H AREA 000E PGRMn'NUMBGR K PERMIT APPROVAL DAAGufl/l PERNn-E71PRU.TION DATE CHECK# PERMIT AMOUNT I SURCNARM Aur. PER CODE RELtIr1'a BT• ' FORM O(629-8a) THIS FORM MUST BE ACCOMPAN EO BY A FACILITY/BITE APPLICATION, FOR M IA',UNL ESS A CURRENT FORMA' NAV RPPN CII FP