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STATE OF CALIFORNIA WATER RESOURCES CONTROL -)ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM = 2sm Wa TANK PERMIT APPLICATION INFORMATION A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z TANK COMPLETE o MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C / K ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8T REMOVE / W c" FACILITY/SITE NAME WHERE TANK IS INFARMTANK-VES❑ NO CA)��/ � . F.i I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N O A. OWNERS TANK ID R al B. MANUFACTURED BY: C.YEAR INSTALLED �Q D. TANK CAPACITY IN GALLONS: U vO D 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. VI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL F-1 3 CHEMICAL PRODUCT ❑4 OIL dPRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑8O EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) II D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.4 C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA B,C,&D A. TYPE OF Q.,lEOUBLEWAUUED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑S POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 A DUNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑�/95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 199 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TATAR OR ASPHALT F-13 VIMIWN3 ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION F91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPES' SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A & 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 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P/ 6 PRECISION TESTING P S ] PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTV T D DATE ATE LST USED MO/YR) 2. ESTIMATED QUANTITY 3WAS TA FILLED WITH I pSUBSTANC� IN 01LLON6 L? ❑VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY M FACILITY ID R TANK ID* GG ( UCS I U I I CURT LOCAL AGENCY FACILITY ID k APPROVED BY NA PHONE N WITH AREA CODE L L p _6, PERMIT NUMBER PERMIT APF VA DATE !PERMIT EXPRIATION DATE JCHECK- PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT♦ BY: FORM 8(6-29-88, THIS FORM MUST BE ACCOMPANIED BTA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C(AIRENT FORMA HAS BEEN FILED DATA PROCESSING COPY