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STATE OF CALIFORNlib WATER RESOURCES CONTR ARD FORM "B': UND ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION C. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��RM TANK -YES ❑ NO TANK DE5CRIPTIDN COMPLETE ALL ITEMS -If UNKNOWN -SO SPECIFY A. OWNERS TANK ID # ' B. MANUFACTURED BY: f C. YEAR INSTALLED ! D. TANK CAPACITY IN GALLONS: Ito, oov II. TANK CONTENTS Ir IA.11, 1, MAHKLU, GUMPLETE ITEM C. IF (A.1), 15 NOT MARKED, COMPLETE ITEM D A. � MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. a 1 UNLEADED S2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL � PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 8D EMPTY ❑ 95 UNKNOWN ❑' 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & G.A.S. B C.A.S. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Eg-1 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 1 SINGLE WALLED A U 2 DOUBLE WALLED �1'�TEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:]4 STEEL CLAD W/FI6ERGLASSREINFORCED PLASTIC B. TANK MATERIAL F-]5 CONCRETE F-]6 POLYVINYL CHLORIDE F-]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP C. MATERIAL ❑ 9 BRONZE © 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-]1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING Er6 UNLINED ❑ 95 UNKNOWN PERMIT AMOUNT ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? a YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION '® 5 CATHODIC PROTECTION Er91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A )1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Ui >5 UNKNOWN A U 99 OTHER APPROVED BY NAME A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A Lh6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(:U,,.�5 UNKNOWN A U 99 OTHER f V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ,�ryry P S I VISUAL CHECK (P *2 INVENTORY RECONCILIATION P S 3 VADDSE WELLS P S 4 ELECTRONIC MONITOR P S 6 GROUND WATER MONITORING WELLS I P S)6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VV VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . ESTIMATED DATE LAST USED (MOIYH) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH H L SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS 1% �6u 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 # TANK ID # EI0 1% �6u o 6 CURRENT L CA AG NCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX 14 DAT - f CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED`W A FACILITY/SITE APPLICATION, FV R M 'A', UNLESS A C RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY ml Z I0 C.7`I