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STATE OFCALIFORNIA , WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM { 4 TANKTANK PERMIT APPLICATION IN .ORMATION V `° ®. CCIINIP.LE A S&AN FORM WITH THE;FOLLOWIN FORMATION FOR EACH TANK:. .• . MARK ONLY ❑ 1.NEW PERMIT ❑ 3 RENEWAL PERMIT pt 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSED'Tq ONE ITEM ❑2 INTERIM PERMIT ��❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE /� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 51 ` 8 TANK REMOVED '! l FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—$O SPECIFY. 3 �© LC. OWNERS TANK ID# B. MANUFACTURED BY: YEAR INST LED H D. TANK CAPACITY IN GALLONS: w II. TANK96NTENTS IF(Ai),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MAR MPLETE ITEM D. I A. Er�1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. LEADE LEADED ❑ 3 DIESEL i+ ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1' 1 PRODUCT 4 GASAHOL E]5 JET FUEL E] 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''If HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: x Ill. TANK CONSTRUC ,ION MARK ONE ITEM ONLY IN BOX A,B,C,&O A.TYPE OF ❑AUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL El 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 UMINUM E]8 IA METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 kl(YD LINING ❑3 EPDXY LINING ❑4 HENOLIC LINING LINING ❑5 GLASS LINING ❑8 UNLINED 9 NKNOWN ii ❑IS UNING MATERIAL-COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO I 99 OTHER D.CORROSION ❑ 1 POLYETHCENE WARP 2 TAR OR ASPHALT3 4 L WRAP El 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION -❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABIOVE 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 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED ' A U 2 DOUBLE WALLED A U -3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 IB GLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U C NCRETE A U 7 STEEL CLAD W/FRP A U 8 1 0%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 NKNOWN A U 99 OTHER •i V. LE 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 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING I] 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 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 B SIGNATURE) , DATE _ a LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# 11 AGENCY# FACILITY ID# TANK ID# 5T EI 1 . 1 1b1 L/ l oI / CURRENT LOCAL AGENCY FACILITY ID li� APPROVED BYNAME - - PHONE it WITH AREA CODE PERMIT NUMBER i3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK K PERMIT AMOUNT .y, SURCHARGE AMT, FEE CODE ._RECEIPT N BY: L /J �t FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY