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STATE OF CALIFORN� WATER RESOURCES CONTR�OARD FORM 'B': UND GROUND STORAGE TANK PROGRAM . TANK TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T ONE ITEM ❑ 7�PERMANENTLY CLOSED 7/// 2 INTERIM PERMIT 4//A��MENDEED PERMIT E16 TEMPORARY TANK CLOSURE ag TANK REMOVED Q y FACILITY/SITE NAME WHERE TANK IS INSTALLED: I ID a 7, C / y FAgM TANK-YES NO :4 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERSTANKID# I B. MANUFACTURED BY: k C. YEAR INSTALLED LA D. TANK CAPACITY IN GALLONS: II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. rD. 1 MOTOR-VEHICLE FUEL [:] 2 PETROLEUM B. 0 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT �4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 0 6 AVIATION GAS 5 HAZARDOUS � 60 EMPTY 0 95 UNKNOWN ED 2 WASTE F-17 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) IFNOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ❑ I DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT E]99 OTHER B.TANK I STEEL/IRON E]2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE El 6 POLYVINYLCHLORIDE E] 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE 10 GALVANIZED STEEL E] 95 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBER LINED 2 ALKYD LINING E]3 EPDXY LINING E:] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING E:] 6 UNLINED 5 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP E]2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION Ej 91 NONE 5 UNKNOWN 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 U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 95 UNKNOWN A U 99 OTHER A( =AU OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBNEC. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRPA U 9 GALVANIZED STEEL A 095 UNKNOWN A U 99 OTHERA U 6 100P 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 WELLS P S 4 ELECTRONIC MONITOR p S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NON p S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3, WAS TANK FILLED WITH GALLONS INERT MATERIAL? E:]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# iTANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME D / � �- PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# By. FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORM'A' HAS BEEN FILED _. J DATA PROCFSCIMO CODV