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.. _,i .,�7W'p �"^✓+�1;03"F�'y ,-ro�n'�t n�„� � ..,,.-p,K.r,. FR'1e+1 r s:r: � ..r r . STATE OF CALIFORNI' s� WATER RESOURCES CONTRO' OARD FORM `B': UNDL..GROUND STORAGE TANK PRG,.RAM TANK G TANK PERMIT APPLICATION INFORMATION w ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED j I FACILITY/SITE NAME WHERE TANK IS INSTALLED: S j `� '> 1- �6 (+ `: VARM TANK - YES ❑ NO �A± 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK IDN B. B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 1 430 D. TANK CAPACITY IN GALLONS: 10 , 1300 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A 0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ® 1 UNL ADD ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL m 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 & C.A.S. 4 C.A S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF }i 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. MATERIAL F11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN U 9 GALVANIZED STEEL A U [�YIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO yx ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 161--t-LI A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A rq) 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% 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 S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P(j� 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLScp S 4 ELECTRONIC MONITOR P S 5 GROUND WAT R MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P/ S 99 OTHER Re Jacket PLD VI- INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) N /A 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN Iv /A GALLONS 3. WAS TANK FILLED WITH INERT MATERIAL? N /A ❑ YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. (915) 348- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE _ RECEIPT # BY: / 7" A - FORM FORM B (6-29-88) THIS FORM MUST BE ACCOM D BY A FACILITY/SITE APPLICATION, FORM `A', UNLESS A CURRENT FORMA' HAS BEEN FILED LOCAL AGFNCY COPY 305-/ COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # E 161--t-LI L k T-) j CURRENT LOCAL AGENCY FACILITY ID # j -- APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE _ RECEIPT # BY: / 7" A - FORM FORM B (6-29-88) THIS FORM MUST BE ACCOM D BY A FACILITY/SITE APPLICATION, FORM `A', UNLESS A CURRENT FORMA' HAS BEEN FILED LOCAL AGFNCY COPY