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WATER RESOURCES CONTROSPARD ,� 5 STATE OF CALIFORNIA �= FORM 'B': UNDE ROUND STORAGE TANK PROGRAM a-� Z TANK TANK PERMIT APPLICATION INFORMATION lQ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T❑AN PERMANENTLY CLOSED TANK ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 1 NEW PERMIT ❑6 TEMPORARY TANK CLOSURE D TANK REMOVED w MARK ONLY 4 AMENDED PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ n^, FARM TANK-YES❑ NO ® c t�� m �_t�Y.iGA /CL, o FACILITY/SITE NAME WHERE TANK IS INSTALLED:SSC]'/ 00I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBE IIANUFAC URED By �-1 /Y A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: e4low C.YEAR INSTALLED B C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL 11. TANK CONTENTS IF(p. ),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT tET FUEL ❑ 6 AVIATION AS A. ❑ 1 MOT OR VEHICLE FUEL 2 PETROLEUM 1 PRODUCT ❑4 GASAHOL ❑5 J ❑3 CHEMICALPRODUCT 4 OIL 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.SEL ) ED] ZAR 5 HADOUS 80 EMPTY 1195 UNKNOWN C.A.S.#: OTOR VEHICLE FUEL, D HAZARDOUS SUBSTANCE STORED 80.A.S.NAM# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C'&0 ❑95 UNKNOWN ❑1 DOUBLE WALLED ❑3 SINGLEWALLEDWITH EXTERIOR LINER ❑99 OTHER A.TYPE OF IDI 4 SECONDARY CONTAINMENT SYSTEM ❑2 SINGLEWALLED 44 ® 1 STEELARON ❑2 STAINLESS STEEL 3 HBERGIA55 ❑ 4 STEELCLAO WIFIBERGLASS REINFORCEDP AS IC El 8100%ME7HANOL COMPATIBLE FRP B.TANK [:]5 CONCRETE ❑fi POLYVINYLCHLORIDE ❑7 ALUMINUM ❑W OTHER MATERIAL ❑9 BRONZE ❑10 GALVANIZE09TEEL ❑95 UNKNOWN ❑3 EPDXY LINING El PHENOLIC LINING ❑ i RUBBER LINED Q 2 ALKYD LINING ❑95 UNKNOWN C.INTERIOR 15 GLASS UNING 6 UNLINED LINING ISUNING MATERULCOMPATIBLE WITH 100%METHANOL? in YES ❑ NO ❑990THFA ❑3 VINYLWMP 4 FIBERGLASS REINFORCED PLASTIC I POlYE1HLENEWPAP ❑2TAfl OR ASPHALT 99 OTHER D.CORROSION ❑ ❑95 UNKNOWN PROTECTION ❑5 CATHODIC PflOTECTION ❑91 NONE LE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICAB A.SYSTEM TYPE A U 1 SUCTION 9 OTHI,H B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AU 95 FI FIBERGLASS PIPE N AAUU91 NONE A U 1 STEEL/IRON A U 2 STAINLESS STEEL A O T STEEL L EEL GLAD W/FRP E(PVC) A U 8100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 99 OTHER A U 9 GALVANIZED STEEL A U 95 UNKNOWN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDAF�Y,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p S 99 OTHER P 6 1 VISUAL CHECK p S 2 INVENTORY RECONCp S 95 UNKNOWN ILIATION V 8 91VNONEE WELLS P S 4 ELECTRONIC MONITOR P 4 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATEDOUANTITYOF INERT MATERIAL? DYES DNO 1. ESTIMATED DATE LAST USED(MO/VR) SUBSTANCE REMAINING IN GALLONS THE BESTOF MY KNOWLEDGE, THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO DA ^ISTRUE AND CORRECT. ` MNAME(PRINTED B. /�- I IDBS CCC114LL 111 LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY# jURISDICTION APPROVED BY NAME pHONEf WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# if PERMIT APPROVAL DATE PERMIT EXPIRATION DATE (� PERMIT NUMBER FEE CODE CEIPTk BY: LL CHECK# PERMIT AMOUNT SURCHARGE AMT. D C FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILMI TA PRO TION, FORM A',UNLESS A CURRENT FORMA' HAS BEEN FILED