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STATE OF CALIFORN WATER RESOURCES CONTROL ^OARD FORM 'B': UNDERXiROUND STORAGE TANK PROGHAM =` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;d MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER NENTLY CLOSED TANK ', ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOS USE TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: F RM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# + B. MANUFACTURED BY: •LJti C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �x7 11. 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 P TROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL T❑ 1 P; DUCT ❑<GASAHOL ❑5 JET F L ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&GAS.# OI G.A;JM All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLS) ❑3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN SYSTEM ❑2 SINGLE WAU-EO ❑4 SECONDARYOONTAINMENT ❑99 OTHER STEELIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCUO W/FIBERGLASS REINFORCED PLASTIC B. TANKF-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER El C. INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑/PHEN IC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINs P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 24UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A V3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U %OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 810696 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER VJJX.rr LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 � P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING C778>1 NONEP S 95 UNKNOWN P 8 99 OTHER TIL VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH (!V, SUBSTANCE REMAINING IN INERT MATERIAL? —]YES ❑ NO GALLONS THIS FORM HAS BE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® 10 0 1 S `f o CD 1 C> 1 > CURRENT LOSILL AGENCY FACILITI ID# APPROVED BY T PHONE N WITH AREA CODE O^C J`Ir. fUjj 0 IPERMIT NUMBER PERMIT APPROVAL DATE PERMITE%PIR ON DATE `V-,IAI'I CMECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEL dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSRENT FORMA' HAS BEEN FILED