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STATE OF CALIFORK m WATER RESOURCES CONT t=BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: NLo 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK IDR 8. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF( 1,),IS NOT MARKED,COMPLETE ITEM D. A. [—].k-Mb/OR VEHICLE FUEL ❑ 2 PETROLEUM B. !_ , (�' ,.� E ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1,PRODUCT E]4 GASAHOL E]5 JET FUEL E] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑•2 WASTE ❑7 METHANOL [D 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,"TER NAME OF HAZARDOUS tOUSTANCE STOWD&C.1.�R C.A.S.R: i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2�NGUE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 +180(1 ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 B.TANK ❑ MATERIAL5 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B IDD%METHANOL COMPATIBLE FRP 1 BRONZE i GAVANIZED STEEL E] 95 UNKNOWN ❑99 OTHER _ ..❑.(,A ABER UNED ❑2 ALKYDUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING i C.INTERIOR _ . LINING ❑5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS,UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ I.7Y I1 .;.WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP [:j4 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 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 I STEEL/IRCY A U 2 STA EBB STEEL A U POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL �/ A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U B /00%METHANOL COMPATIBLE FRP ' A U 9 GALVANIZED STEEL A U 95 y KNOWN A U 199 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY IDR TANK ID R m = = lololll a o I U In 131 CURRENT LOCAL AGENCY F IUTY IDI APPROVED BY NAME PHONE N WITH AREA CODE -DO?-ou30 I 10 1 LCIOCKO PERMIT APPROVAL DATE PERMIT EXPIRAT DATE PERMIT AMOUNT CHARGE AVT. — FEE CODE 1 PTI BY: C\�-- FORM B(6-29-ee) THIS FORM MUST BE ACOOMPANIEDBY' A FACILIT//SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED