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STATE OF CALIFOR11W WATER RESOURCES CONIW BOARD 5' >F FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION .. Is COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 ITERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: i— FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �00 L.2 00d 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. 1 UNLEADED F-]2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [:]5 HAZARDOUS ❑ 80 EMPTY [-]95 UNKNOWN El2 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. # C.A.S. #: IV. 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 SYSTEM INGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER B. CONSTRUCTION 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%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN _] ❑ 99 OTHER A U 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED 2 ALKYD LINING F-]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ED -6 -MINED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER rlr19V%X IIMr%JnMJ%1 IVI'• Ultlt4Lt A Ir NCfuvr UPSVUIVU, v Ir UIVUGSt]RVUIVU, ov In Ir P1rrLILJ%o LC a SYSTEM TYPE A U 1 SUCTION A &P PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER LSURCHARGE AMT. AU 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 U 6 CONCRETE A U 7 STEEL CLADW/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. i 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 P 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 3. WAS TANK FILLED WITH FACILITY ID # I ILI j (I I1616(5 SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES [:]NO m K r-- / �_ GALLONS 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 & SIGNATURE) DATE tl � fi�A I Lq 3o1,41 WA COUNTY # JURISDICTION # AGENCY # E[ FACILITY ID # I ILI j (I I1616(5 TANK ID # ]:1]— CURMT LOCAL AGENCY FACILITY ID # -)- 1: �--:: � �-- - �t" n: m K r-- / �_ APPROVED B NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE CHECK # PERMIT AMOUNT LSURCHARGE AMT. FEE CODE RECEIPT # h ft BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED BY ((FACILITY/SITE APPLICATION, P V HM 'A', UNLESS A CURRENT FORM W HAS BEEN FILED DATA PROCESSING COPY CJ1