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STATE OF CALIFORNWATER RESOURCES CONTRI 30ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM I~�: TANK TANK PERMIT APPLICATION INFORMATION < ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LtoKTANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: w7 9 FARM TANK-YES NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK IDR �" B. MANUFACTURED 8Y: C. YEAR INSTALLED Lvv.,K/ D. TANK CAPACITY IN GALLONS: DD() II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. gl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL E211-`PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 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.R AI-LC.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑I DOUBLEWA-ED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WNIED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRm ❑6 POLYVINYLCHLORIDE ❑ 7 LUMINUM ❑ B IW%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 OLICUNING LINING ❑ 5 GLASS UNING ❑6 UNLINED 95 UNKNOWN,, ❑ IS UNING MATERIAL COMPATIBLE MTH 100Y.METHANOL? ❑YES ❑ NO OTHER ✓_-_ D. PROTECTION ❑5 CATHODIC PROTECTION ❑91TANONE ASPHALT �UN N WNRA,P ❑W OTHER RLASS REINFORCED FUSTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A %UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER V,eLEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ol P'VT P B 6 PIECISIONVISUAL ETESTING P S 7 PRESSUCK 2 RERECILLATION p g 91 VNONEE WELLS P S 95EUNKNOWN C MONITOR P 8 99 OTHER TH RD WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI TED DATE LAST USED(MO/YR) 2.PSTIMATED QUANTITY OF 3.WAS NKFILLED WI OALLONB TH ^ BSTANCE REMAINING IN ERIAL7 ❑YES ❑NO 7'A 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 R JURISDICTION N AGENCY R FACILITY ID N TANK ID N CURflEN LOCAL AGENCY FA ILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 2/PL/ PERMIT NUMBER PERMIT APPROVAL DATE PERYR EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT N BY: FORM B(6-29-63) THIS FORM MUST BE ACCOMPANIEdBY A FACILITY/SITE APPLICATION, FORM'A',UNLESS AflRENT FORMA HAS BEEN FILED DATA PROCESSING COPY