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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM am ry .o TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z TANK ❑ MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS / ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: W I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN '�// B. MANUFACTURED BY. C. YEAR INSTALLED Lfjv(J�i D. TANK CAPACITY W GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. El UNLEADED ❑2 LEADED 3 DIESEL ❑ ❑ PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT 4 OIL ❑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 CA S.W HAZARDOUS SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,•D A,TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑ 5 WNCRETE F-16 POLYVINYLCHLORIDE F-17 ALUMINUM F-18100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL �UNKNGWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 1;4UNKNOIMN UNING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO Eal0THER ! D CORROSION ❑ S CATHODIC WRAP PROTECTION ❑91AR OR NONE ASPHALT ❑3 VINYL NKNOLMIP ❑4 FIBERGLASS REINFORCED PLASTIC ❑ ❑ ❑ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE dl A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A8 CONCRETE A U 7 STEELCLAOW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(.UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S P 5 1 VISUAL CHECK S- 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMAT DATE EAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TA FILLED WITH SUBSTANCE REMAINI G INET TRIAL? ❑YES ❑ NO 24444 GALLONS �C� THIS k6RM 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 N JURISDICTION N AGENCY N FACILITY ID N TANK ID N ® I vo I Z2-- s I 9 I I nn RRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE PA C� O 1 A! PERMIT NUMBER PERMIT APPROVAL DATE PERMIJ EXPIRATION DATE CHECK N PERMIT AMOUNT I fURCHAROE AMT. FEE CODE BEGEIPT N BY: 1 FORM a 16-29-56; THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 001ARENT FORMA' HAS BEEN FILED 1 DATA PROCESSING COPY -