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STATE OF CALIFWATER RESOURCES CONTROgOARD FORM 'B' '.'UNDERGROUND STORAGE TANK PROGRAM ;.TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .y4. MARK ONLY �,.❑ I NEW PERMIT. ❑U RENEWAL PERMIT ONE ITEM !.❑2 INTERIM PERMITED❑6 AMENDED PERMIT ❑6 TEMPORARY TANK ❑ T PERMANENTLY CL FACILITY/SITE NAME WHERE TANK 18 INSTALLED: CLOSUgE B TANK REMOVED L TANK DESCRIPTION COMPL E ALL ITEMS•IF UNKNOWN ARM TANK•YES NO ❑ N A. OWNERS TANK IDM SO SPECIFY M.� _ p _ C. YEAR INSTALLED B. MANUFACTUgEO BY: C /.S CLD 11. TANK CONTENTS D. TANK CAPACITY INC ALLONS: IF(A.1),19 MARKED,COMPLETE ITEM C.IF JAI IS NOT MARKED,COMPLETE ITEM D. 2 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT D. C• ❑ 1 UNLEADED ®2 LEADED 1 OIL ❑3 DIESEL ❑ 5 HAZARDOUSED ❑ 1 PRODUCT ❑/ GASAHOL 5 JET FUEL ❑6 AVIATION GAS 80 EMPTY ❑95 ED UNKNOWN ❑2 WASTE ❑ I METHµOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF N07 MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.8 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOII A,0,C,&D CAS.E: A.TYPE OF ❑ I DOUBUWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM - :: 2 SINGLE WALLED ❑K SECONDARY CONTAINMENT ❑95 UNKNOWN %OTHER I STEEL/IAON �2 STAINLESS STEEL B.TANK - ❑ 5 CONCRETE - ❑S RBEXLASS ❑6 STEEL CIADW/FIBERGLASS REINFORCED PLASTIC MATERIAL'; ❑6 POLYVWYLCHLOROE [Ell ?ALUMINUM 9 BRONZE a I�%METMANDL COMPATIBLE FRP 1(, ❑ _ ❑ 19 GALYANRLD STEEL ❑ %UNI(NOWN ❑ OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2ALKYO LINING ❑3 EPDXY LINING /PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ ❑ ISUNING IUTEFI&COWARBLEWITH190%MET W O5 UNKNOWN ED YES ❑NO ❑9 D. CORROSION PROTECTION ❑ I Pp.YETMLFNE WRAP ❑2 RAR ORAS^HALT ❑3 VWYLWRAP ❑/FIBERGLASSREINFORCEDPUSTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE %UNKNOWN ❑ ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PgEI " B. CONSTRUCTION A U 1 SINGLE WALLU ED A A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 9 2 DRE OUBLE WALLED A V 3 LINED TRENCH 9 OTHER A U 91 NONE A 85 UNKNOWN A U 99 OTHER A U 1 STEEUIRON U CMATERIAL U 2 STAINLESS STEEL A U 3 POI A U 9B OTHER CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE . 'A U 5 ALUMINUM A U 6 CONCRETE A U 9 OALVµgED$TEFL A U 95 UNKNOWN A U T STEEL CLAP W/FRP A U e 10096 METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P B 2 INVENTORY RECONCIUATION P B 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 18 8 PRECISION TESTING P 8 I PRESSURE TESTING P B 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE flEMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ NO TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. ZZUANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION 8 AGENCY P FACILITY ID 8 "�-1•F—�I :� �+�—�J � /J/ TANK ID 8 CURRENT LOCAL AGENCY FACILITY ID P / . APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER ' PERMIT APPROvI DATE PERMIT EXPIRATION DATE CHECKI bU PERMITAMOUNT . ,. gCHARGE AVT• FEE CODE ' , ECEIPTI BY: FORMBL6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SIE APPLIcannN Cno„ .., .___..