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STATE OF CALIFORNI• WATER RESOURCES CONTR(OOARD " `:. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM W'' TANK TANK PERMIT APPLICATION INFORMATION ; . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -^�" Z 10 MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [JB-TANK REMOVED O N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 28 q { t.1 FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W. A. OWNERS TANK IDN d I (Z ( I B. MANUFACTURED BY. C. YEAR INSTALLED 1 q%D, I D. TANK CAPACITY IN GALLONS: 1 1 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ©'1 A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C I�-TtfNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT F-14 OIL �ODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY I]95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Ef 2 SINGLEWALLEO 4 SECONDARY CONTAINMENT ❑ 99 OTHER LJ ""EL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVNd CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER - C. INTERIOR F-11 RUBBERLINED [:] 2 ALKYD LINING F-] 3 EPDXY LINING E]4 PHENOLIC UNING LINING ❑ 5 GLASS LINING �UNED ❑ 95 UNKNOWN '1 I I� ❑ ISUNING MATERIAL COMPATIBLE WITH 0%METHANOL? E]YES N �YES O OTHER L.q D. CORROSION ❑ I POLYETHLENEWRAP AR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AIJ,,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPAT12 FRP A U 9 GALVANIZED STEEL A"S 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 IVISUALCHECK P S 2 INVENTORY RECONCILIATION S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P. 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE• 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORR APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY (T COUNTY# JURISDICTION# AGENCY# FACILITY IDM TANKID# ® � � opliTF01 I I 7� 1 CURRENT LOCAL AGEyOY F®ILITY I APPRQVED BY NAME PRONE#WJTN AREA CODE III PERMIT NUMBER S PERMIT APPROVAL DATE(E A,�P-EJ\RMIT EXPIRATION DATE I CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: \ FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY