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STATE OF CALIFORNIA WATER RESOURCES CONTRC�ARD FORM `B': �•':.;'�� Q� UNDERGROUND STORAGE TANK PROGRAM TANK '� " TANK PERMIT APPLICATION INFORMATION . �:m ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a [FACILITY/SITE RK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ' NE ITEM INTERIM PERMIT ❑ 7 PERMANENTLY CLO K ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE NAME WHERE TANK IS INSTALLED: Z^L E Y 8 TANK REMOVED D I _1 PT Ke S? S- a edri ARM TANK-YES NO G I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9S LD/ (� A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Qb� II. TANK ONTENTS IF(q,l),IS MApKED,COMPLETE ITEM C.IF(q,1).IS NOT MARKED,COMPLETE ITEM D A_ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ q OIL B C' ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL IV PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL Ej 6 AVIATION GAS ❑5 HAZARDOUS D. IF NOT MOTOR VEHIC ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE 11D 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM ,BELOW) LE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,E C,8 D C.A.S.H A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 21195GLEWALLED ❑4 SECONDARY CONTAINMENT UNKNOWN ❑99 OTHER B. TANK 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCREIE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99,OTHER ALKYD LINING 3 EPDXY LINING C. INTERIOR 1 RUBBER LINED ED 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED Ep 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%MEIHANOL9 YES ❑ NO �99 OTHER D. CORROSION i POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 INYLWRAP PROTECTION ❑4 FIBERGLASS REINFORCED PLASTIC 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE [C. SYSTEM TYPE A 1 SUCTION !!ES RE CONSTRUCTION A U 1 SINGLE WALLED - !AU 3 GRAVITY A U E!!fn KNOWN A U,.99 OTHERE WALLED3 LINED TRENCH A U KNOWN A U 99 OTHERA U 1 STEEL/IRON S STEEL3 POLYVINYL CHLORIDE(PVPIPE A U 91 NONEMATERIAL A U 5 ALUMINUM ETEA U 9 GALVANIZED STEEOWN 7 STEEL CLAD W/FRP ANOL COMPATIBLE FRP 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P g 3 VADOSE WELLS P S q ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS O P 6 PRECISIONTESTMG P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S ss OTHER 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 9.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# V O FACILITY ID# TANK ID# CURRENTLOCALAGENCY FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 2 CHECK# PERMIT AMOUNT SURCHARGE AMT. /�� FEE CODE CEIPTk BY: 1- FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FO Aux HAS BEEN FILED DATA PROCESSING. COPY Uy