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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ;mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;e-- MARK MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 'SCHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q tA FAflM TANK-YES❑ NO t 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY - A. OWNERS TANK ID# B. MANUFACTURED BY: A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTORVEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 61-PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPtt ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUE ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.p: III. TANK CONSTRUCTION XARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ i DOUBLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON STAINLES95IEEL ❑3 FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 YWNYLCHLORIDE ❑ 7 ALUMINUM ❑S 109°6 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 VANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD ING F-13 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED E]95 UNKNOWN [-] IS UNING MATERIAL COMPATIBLE WITH 10D%M ? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR ON ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, ' UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i 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 WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18ERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A 7 STEEL CLAD W/FRP A U 9 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 1 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMAF OR S FOR SEC DARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 8 5 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED GATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF LONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] NO] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST NMY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCALAGEENCY USE ONLY COUI Q-�-1-r TLJ�LJ �JURISDICTIONAOEFACILITY IDR L/.f'� TANK ID p / ,� / IdolTI CURRENT LOCAL AGENCY ILITY IDp APPROVED BY NAME - PHONE#WITH AREA CODE E a - -�� PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI AFACILITYYSITEAPPUCATION, FORM 'A',UNLESS A ENT FORY'A' HASBEENRLED DATA PROCESSING COPY