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STATE OF CALIFORNIE WATER RESOURCES CONTROL ^OARD FORM 'B': UNDERGROUND STORAGE TANK PROUNAM (�Z4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMEENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: N 1 )-T — 7 ,-77,9 FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL A. OWNERS TANK ID R ❑ 1 PRODUCT B. MANUFACTURED BY: ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN C. YEAR INSTALLED ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 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 8 C.A.S. R C.A.S. K: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100% METHANOL COMPATIBLE FRP A U 95 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 AM LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNUNED A U ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METKWL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCEDRASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLEA IFABOVEGROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U I 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 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR 8 FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED (MO/VR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH m IN SUBSTANCE REMAININGGALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED IINDFR PFNAI TV OF PERIL 1RY AND TO TNF REST OF MV KNnWI PDGF IS TRI IF AND nnRRFOT APPLICANT'S NAME (PRINTED A SIGNATURE) DATE -UI AL AUCIV COUNTY N JURISDICTION X AGENCY k FACILITY ID M TANK ID 8 m = = I Old T773'Yj CURRENT LOCAL AGENCY FACILITY IDX I APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER I PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE I CHECK N I PERMIT AMOUNT I SURCHARGE AMT. I FEE CODE I -RECEIPT • 1 liia 'ORM B (6-29-66) THIS FORM MUST BE ACCOMPANIL'nY A FACILITY/SITE APPLICATION. FORM 'A'. UNLESS AAATURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY