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STATE OF CALIFORNI WATER RESOURCES CONTRRD FORM `B': UNDER OUND STORAGE TANK PROM M TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK ZO NLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C MARK O ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED yn FARM TANK-YES❑ NO (� FACILITY/SITE NAME WHERE TANK IS INSTALLED: (J`i � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERB. MANUFACTURED BY: S TANK ID N D. TANK CAPACITY IN GALLONS: 1000 C. YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. G 1 UNLEADED 2 LEADED �DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ❑ ❑ ❑ PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT 4 OIL ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.p: ,� A HAZARDOUS SUBSTANCE STORED&C.A.S.# ZA III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 SINGLEWALLEO ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER [?r�ISTEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOLOOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 APD LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C. INNING R ❑5 GLASS UNING 6 UNLINED ❑ UNKNOWN V✓✓"" _ ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER 0. CORROSION ❑i POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A W SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION V 1 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 FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U�''61 CONCRETE A U 7 STEELCLADW/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AAI/!5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S p 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE E 2. STI ATED QUANTITY OF 3.W TANK FILLED WITH 1. ESTI ATED DATE LAST USED(MO/YR) SU Tj(.NCE REMAINING IN 1 ATERIAL7 DYES [1) NO /V GALLONS T IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILTY ID# TANK ID# D � I �� EH= APPROVED BY AME �� PHONE#WITH AREA CODE CURRENT LOCAL AAGENCY FA ILITV IDM 416 I L PERMIT NUMBER PERMIT PR DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE MT. FEE CODE RECEIPT p BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/ I SAPPROCION , FORMNG 'A;,UNLESS A MARENT FORMA' HAS BEEN FI OLED