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YSTATE OF-CALIFORNIA' WATER RESOURCES CONTROL BOARD •��`,.,.., �.• FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK C/ TANK PERMIT APPLICATION I FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR-EACH TANK..'. :,•, `'stoe '' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 MANENTLY TANK ONE ITEM ❑2 INTERIM PERMIT ❑4-AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED V jop FACILITY/SITE NAME WHERE TANK IS INSTALLED- F RM TANK-YES❑ NO 1 O • I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY `��7 A. OWNERS TANK IDB.11 B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1), S NOT MARKED,COMPLETE ITEM D. A. IV, MOTOR VEHICLE FUEL ❑ 2 PETROLEUM j0, [:] I UNLEADED E] 2 LEADED 3 DIESEL F—] B.3 CHEMICAL PRODUCT ❑4 OIL I1 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7.METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1 z.., HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: R "� Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF DOUBLE WALLED F-13 SINGLE WALLEO WITH EXTERIDR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL 4,7XMINUM 3 FIBERG ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL, 5 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LININGLINING ❑ 6 UNLINEDNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO �THER Q.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALTV95 WRAP ❑4 FIBERGLASSREINFORCED PLASTIC v PROTECTION [—]5 CATHODIC PROTECTION ❑91 "NONE NOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF A80VE 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 U 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A'j U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A,u95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON Al U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP. A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 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 S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 1 - 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 F] 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&SIGNATURE) DATE a , Il LOCAL AGENCY USE ONLY 1 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L�11J El I I I Do 12-l.-qlqofI 1/ Fololol ? l I CURRENT LOCAL AGENCY FACILITY ID# I APPROVED BY NAME PHONE#WITH AREA CODE A/l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT ,,, SURCHARGE AMT. FEE CODE . -RECEIPT# BY: �� FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED I. DATA-PROCESSING COPY .