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STATE OF CALIFORNIP WATER RESOURCES CONT BOARD FORM B': UNDERGROUND STORAGE TANK'- i RAM TANK TANK PERMIT APPLICATION INFORMATION ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING! FORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLOS K ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E]B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: J 2'ellr M TANK-YES❑ NO .0& I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ��ij A. OWNERS TANK ID# B. MANUFACTURED BY: Vc C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: QOO ele II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT F-1 B.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 NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A.TYPE OF UBIE WALLED ❑3 SINGLEWALLEDWFIH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Z 2 SINGLE WALLED ❑ 4 SECONDARYOONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE n 7,I MINIUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ ,L-orf/10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER F-1 1 RUBBERLINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING NOUC LINING C. INTERIOR ❑5 GLASSUNING ❑6 UNLINED 95 UNKNOWN LINING ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION JrIJ 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS Q 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY O SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? �YES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# C7 � 3 5 e2l O ;2, FCHECK ;77 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE T SURCIUIROE AMT. FEE CODE RECEIPT N BY: FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIE BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY