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STAYS OF CALIFORNQ WATER RESOURCE'S CONTR( OARD .... - . FORM 'B': UNDERGROUND STORAGE TANK PROGRAM- TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING I MATION FOR EACH TANK, MARK ONLY ❑ 1 NEIN PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑0 TANK REMOVP FACILITY/SITE NAME WHERE TANK IS INSTALLED: TANK-YE NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—!SO SPECIFY A OWNERS TANK ID 8 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: H. TANK 92NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. El UNLEADED 'Rr2 LEADED' ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL EI. PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 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.N CA.S.A: Ill. TANK CONSTRU9TION MARK ONE ITEM ONLY IN BOX A,,B;C,a D A.TYPE OF 6MLE WALED ❑3 SINGLE WALLED WITH EXTERIOR bNER ❑%uNK1IOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OBIER 1 STEELIM 2 STAMUSS STEEL 7RMBE 4 STEB CUDWIRBERGLASSREffORCFDPIASTIC B.TANK ❑S CONCRETE ❑6 POMMM atoRDE ❑ ❑8 100li METHANOL COMPATIBLE RTP MATERIAL9 BRONZE 10 GALVANIZED STEEL ❑93 OTHER 1 RUBBER UN® ❑2 AU(YD UNING 3 EPDXYLINING 4 PHENOLIC UMNG G INTERIOR �R ❑5 GLASS LINING ❑6 UNLINED 9K!IOWN E]S LINING MATERX COMPATIBLE WITH 10D%IIEf WVNOL4 ❑YEs No OTHER D.CORROSION ❑ 1 POLYMAD E WRAP ❑2 TAR OR ASPHALT ❑3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTMTIDN ❑9t NONE UNKNOWN ❑99 OTHER ' IV. PIPING INFORM N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRDN A U 2 STAINLESS STEEL AU 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A *CONCRETE A' U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER L K DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S;FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. k;JP 9 1 VISUAL CHECK P 8 2 INVENTORY RECONCIUATION P 9 3 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P 9 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 97 PRESSURE TESTING P S 91 NONE P 9 95 UNKNOWN P S 99 OTHER y VI. INFORMATION ON TANK PERMANENTLY CLOSED.IN PLACE 1. ESTIMATED DATE LAST USED(MOIYR) 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,1S TRUE AND CORRECT.,,, APPLICANTS NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY 1 FACILITY 10/ TANK ID 8 ® FoTo 3 r1' l7 0= 7_7 CURRENT LOCAL AGENCY FACILITY ZD•• APPROVED BY NAME PHONE i wrrH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E 04MTION DATE CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ BY: f FORM B(6-29-86) THIS FORM MUST BE ACCOMPAAI'&9Y A FAC;UTY/SITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' HAS BEEN FILED \ nATA 0R0rFSFI--rhnv -