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. STATE OF CALIFORK,�:-. f; WATER RESOURCES CONTE'' JOARD rs.-. ,•. FORM `B': UNDERGROUND STORAGE TANK PROGRAM m" TANK PERMIT APPLICATION INFORMATION -- TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLYD/ El ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0'5(:HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMO ;n 7 FARM TANK-YES❑ NO »: FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 _j l;�(/y' E�'r -�. / = 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID B. MANUFACTURED BY: 6 (JN C. YEAR INSTALLED D. TANK CAPACITY IN GALLON -,(0c 11. TANK CPWENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. L A ff7lMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT F-] 4 OIL r PRODUCT i/ ❑ 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 C.A.S. 1 �/ HAZARDOUS SUBSTANCE STORED&C.A.S.# x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTE 1� ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER /5)❑ 1 STEELMRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAS/ / F-15 CONCRETE El6 POLYVINYLCHLORIDE F-]U�95 AL UM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER 1d ❑ 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING F-14 PHC LINING ❑ 5 GLASS C. INTERI RLINING ❑6 UNLINED / ENO UNKNOWN LINING S LINING MATERIAL COMPATIBLE WITH 100%METHA OL? YES NO ❑99 OTHER ' D.CORRO 0 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL 'AP ❑4 FIBERGLASS REINFORCED PLASTIC PROTEC I N ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 U 2 PRESSURE A U 3 GRAVITY A U 99 OTHERB.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A (y,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUU 95 UNKNOWN A U 99 OTHER �. 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS p-�S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS f�TA P S 6 PRECISION TESTING P S 7 PRESSURETESTING DS 91 NONE r/�' 95 UNKNOWN P S 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 INEPT MATERIAL? ❑ YF, ❑ ,NQ GALLONS THIS FORM HAS 9EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY F,t /7OUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I El I IG1LA c� 05 CWWNT LOCAL AGENCY FACILITY ID# P OVED BY NAME PHONE#WITH AREA CODE MIT NUMBER PERMIT APPRO ALD TE PERMIT EXPI TION DATE CHECK# PERMIT AMOUNT = SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORMZ�UtLim j A,CURRENT FORM'A' HAS BEEN FILED n—, nnnrrec rrrr_ rrnn�'