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STATE OF CAL IFORN ' WATER RESOURCES CONTF FORM `B': UNDERGROUND STORAGE TANK PROGRAM __ m TANK TANK PERMIT APPLICATION INFORMATION a ;> TAIN•` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. = - MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C D NK RiM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE 1 ONE ITEM ❑ 2 INTE ❑ 111 FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� S NAL 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY , A. OWNERS TANK ID# (1/)(�(a�J(,�t�L' B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: Q C. YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED 2 LEADED 3 DIE EL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ N 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOW D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF C.A.S.#: IHAZARDOUS SUBSTANCE STORED&CAS # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL F-]9 BRONZE M 10 GALVANIZED STEEL k! 91UNKNOWN M 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LININGnYHENOLIC LINING C. INTERIOR 5 GLASS LINING F-16 UNLINED �� 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO F-] 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-�2 TAR OR ASPHALT 3'VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE d95 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 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/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 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,- , , . 1 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES F7 NO I I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8,SIGNATURE) DATE LOCAL AGENCY USE ONLY E JURISDICTION# AGENCY# FACILITY ID# TANK ID# AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE �1�1�1/K 3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANA FACILITVSITE APPLICATION, FORM `A',UNLESS A(.JRRENT FORMA' HAS BEEN FILED