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STATE OF CALIFORN _. WATER RESOURCES CONTR BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;„ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION F-17 PERMANENTLY C OSED aANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / 7- RM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY go A. OWNERS TANK ID# ilk B. MANUFACTURED BY: l< C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. S W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL 00 ❑3 CHEMICAL PRODUCT Y01611- ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ ET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN �2 WASTE ❑ 7 METHANOL VOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� O HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: xiII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ I BLE WALLED F-] 3SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM EY2 SINGLE WALLED ❑4 SECONDARICONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑28TAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TAMC ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 MINUM ❑8100%METMNOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL EV95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 P ENOUC UNI NG LINING ❑ 5 GLASS LINING F-16 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR ON ASPHALT ❑3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A U 5 ALUMINUM A B CONCRETE A U 7 STEELCLAD W/FRP A U 18 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. y{ P S I VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS )^ 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 OUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL' �i L�YES E]NO /V//--GALLONS vow L THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 00t LE3 ]Kl I OOo CURRENT LOCAL AGENCY FACILI # fA APPROVED Bp pppgE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3 7-95) THIS FORM MUST BE ACCOMPANICU BY A FACILITY/SITE APPLICATION, FORM 'A',, 1 JRRENT FORMA' HAS BEEN FILED w jATA PROCESSING COPY