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STATE OF CALIFORNP - WATER RESOURCES CONTRA BOARD FORM `B': UNDERGROUND STORAGE TANK PRftRAM TANK / TANK PERMIT APPLICATION INFORMATION /� CCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ANENTLY ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVEI)O 3G IGG ❑ ND `' FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3of ,e o4 R K-YES CA) I. TANK DESCRIPTION 9OMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: CO C. YEAR INSTAL �l7 1 D. TANK CAPACITY IN GALLONS: It. TANK C TENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY E]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 8 C.A.S.N C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER in 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81DD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2ALKYD LINING ❑ 3EPDXY LINING n'I PAEN LIC LINING C.INTERIOR ,fly,/ LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 9 KNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IDN%METHANOL? ❑YES NO 99 OTHER D.CORROSION ❑ I POLYEIHLENE WRAP ❑ 2 TM OR ASPHALT ❑ 3 V LWRAP ❑d FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION E] 91 NONE 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 jtANGUE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED, 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS YY1166\\ P 8 6 PRECISION TESTING P 8 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 SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? ❑YES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION# AGENCY p FACILITY ID 0 TANK ID p 3 = [= = I 1 1 -710 / y CURRENT LOCAL AGENCY FACILRY ID 11 APPROVED BY NAME PHONES WITH AREA CODE S J/ -f v PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERYIT AYOUNT SURCHARGEAMT. FEECODE RECEIPTS BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY