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STATE OF CALIFORNItO WATER RESOURCES CONTRO' 10ARD FORM 'B': UND�R`16ROUND STORAGE TANK PRO IAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q<CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED:TANK-YES ci Q N I. TANKDESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# Zji— B. MANUFACTUREDBY: C. YEAR INSTALLED `j&lkJ D. TANK CAPACITY IN GALLONS: ! D D 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAMEOF HAZARDOUS SUBSTANCE STORED & C AS # CAS #'. Ill. TANK CONSTRUCTION MARK ONE ITEC ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 UBLE WALLED ❑ 3SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A 1 STEBUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 STEEL/IRON A U 2 STAINLESSSTEEL ❑ 1 RUBBER LINED F-12 DLINING F—]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING fi UNLINED 5 ALUMINUM A U 6 CONCRETE 95 UNKNOWN U 7 STEEL CLAD W/FRP A U E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E] YES [:]NO ,4� / E14 OTHER Fmmk D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 295 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3. W S TANK FILLED WITH TANK ID # I Ao � 1721 - ANCE REMAINING IN 0. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER PEVmtr EXPIRATI N DA B. CONSTRUCTION A &A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B I0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(U)95 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. 1'1 P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS IN/ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P 8 99 OTHER { VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTI ATED DATE LAST USED (MO/YR) 2. EST ATED QUANTITY OF 3. W S TANK FILLED WITH TANK ID # I Ao � 1721 - ANCE REMAINING IN MATERIAL? E:] YES E] NO APPROV�YINNAME / GALLONS A45k THIS F( RM HAS BEEN COMPLETED UNDER PENAL(!Y OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY # JURISDICTION # AGENCY # FACILITY ID # d 1 l TANK ID # I Ao � 1721 - CURRENT LOCAL AGENCY F LITY CIID # 7 APPROV�YINNAME / PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEVmtr EXPIRATI N DA CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AJORRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY W N