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WATER RESOURCES CONTR OARD STATE OF CALIFORN� FORM `B': UNDERGROUND STORAGE TANK PROGRAM 'B TANK PERMIT APPLICATION INFORMATION 4 Fa,�, 7;a TAN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED 09 ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT v' FARM TANK-YES❑ NO -� FACILITY/SITE NAME WHERE TANK IS INSTALLED: I (� I. TANK DESCRIPTI7:UZWV7 -IF UNKNOWN—SO SPECIFY -1 B. MANUFACTURED BY:A. OWqA NERS TANK ID# PC.YEAR INSTALLED I�S D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 1 P ❑ RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ��HEMICALPRODUCT 4 OIL ❑ 2 WASTE ❑7 METHANOL �pTHER(DESCRIBE IN ITEM D,BELOW) ❑ 80 EMPTY 5 HAZARDOUS ❑ ❑ 95 UNKNOWN �j D. IF NOT MOTOR VEHICLE FUEL,ENTERNAME OF N C.A.S.#: �'7 1 L4 HAZARDOUS SUBSTANCE STORED&C.A.S.# I l I n r" III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF ❑' ❑ 99 OTHER SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ��TEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR UNLINED ❑95 UNKNOWN LA 'V LINING ❑ 5 GLASS LINING l f ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO -grOTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR ORASPHALT F-13 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONONE 0 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE FMATERIAL A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U S ALUMINUM A/U�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(U 'y5 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC N MONITOR P S 99GROUN WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF NERT MATERIAL? ❑YES ❑ NO 1. ESTIMATED DATE LAST USED M' SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOonTE DGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# APPRO D BY NAM HONE#WITH AREA CODE CURRENT LOCAL AGENCY ACILITA s- PERMIT NUMBER `J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE` IIJJJ RECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS MARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _