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J 1 A 11: ur CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: F�1 FARM TANK-YES NO Li I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWI, SPECIFY BO FAOWNERS TANK IDNB. MANUFACTURED BYAR INSTALLED D. TANK CAPACITY IN GALLONS: W 0 ovv -3 If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O A. I MOTOR VEHICLE FUEL2 PETROLEUM 13 ❑ Q ❑ 1 UNLEADED 2 LEADED ❑J DIESEL 3 CHEMICAL PRODUCT ❑ A OIL 1 PRODUCT ❑O GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDDUS ❑Ib 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 6 C.A.S.N CAS.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D rB.TANK E OF ❑ I DOUBLEWALLM ❑3 SIWLE WALLED WI N D TDOOR LINER ❑95 UNKNOWN TEM 2 SINGLE WANED ❑/SECONDARY CONTAINMENT ❑99 OTHER I STEELIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑A STEEL CLADW/FIBERGLASS REINFORCED PLASTICERIAL ❑5CONCREE ❑6 POLYVINYL CHLORIDE ❑ 7ALUAIMN ❑6IBo%MMMOLODMPATIBLEFM ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBEAUNED ❑2 AIXYD UMNG ❑3 EPDXY LINING ❑1 PHENOLICUNNG LINING ❑5 GIASSURING lf)5 UNLINED ❑95 UNKNOWN ❑IS UINNG MATERAL COMPATIBLE WITH IW%METMNM? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 FOLYEUUKWRAP Lf 2 TARORASPHALT ❑3 VINYL WRAP ❑A FIBERGLASSIEINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A Uif" SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLEO A U 3 LINED TRENCH A I NONE A U 95 UNKNOWN A U "OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVCI A U A FIBERGLASS PIPE A U 91 NONE G MATERIAL A 62 U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 I VISUAL CHECK ► B 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P B S ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS • B 6 PRECISION TESTING P 6 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE FL 1. ESTIMATEDDATE LASE VSE0IM0/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN LLONS INERT MATERIAL? ❑YES ❑NO GA THIS FORM HAS BEEN COMP.LETEO UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE 4 LOCAL AGENCY USE ONLY 3� JURISDICTION � AGENCY• � FACILITY IDN TANK ID N O 1 1 0 6 O C7 0 2 CURRENT LOCAL AGENCY FACIIJTT IDB APPROVED BY NAME Ong-� L A I PHONE B WITH AREA CODE PERMIT NUMBER C E- PERMIT APPROVAL DATE PERMIT EE►IMTON DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE COD[ RECEIPT B BY: �• T FORM B W29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A�IRENT FORMA' HAS BEEN FILED DATA PROCFSCWr Y;Y1DV