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STATE OF CALIFORNIA WATER RESOURCES CONT BOARD FORM `B': UN RGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION 'S TANK T COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ©-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK 19 INSTALLED: (U FARM TANK-YES❑ NO •o I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID 4 V. 8, MANUFACTURED BY; to1 C. YEAR INSTALLED c l D. TANK CAPACITY IN GALLONS: ! 'Cj II. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. � A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [a'-UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL E? -PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL © 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1 METHANOL ❑ 9s OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.4: I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D A.TYPE OF ❑ I OOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM a2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER �I STEELPRON F-]2 STAINLESS STEEL ❑ 3 FIBERGLASS E] WO4 STEEL O W&BERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] I ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ® 1 RUBBERUNED F-]2 ALKYD LINING ❑ 3 EPDX/LINING ❑4 PHENOUCLINING I�''I LINING L_1 5 GLASS LINING ❑6 UNLINED E95 UNKNOWN ❑ 15 LINNG MATERIAL COMPATIBLE WITH 100%METHAWL7 ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I R)LYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE r?_m__'uNKNOWN ❑99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION AU I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 9S UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESS STEEL 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 WIFHP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A-t"" 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 b 1 VISUAL CHECK l-1 S 2 INVENTORY RECONCILIATION P b 3 VADOSE WELLS P b 4 ELECTRONIC MONITOR P 8 5 GROUND WATER ONITORING WELLS Pr 6 PRECISION TESTING P S 7 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 LAST USED(MONFI) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING!N 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 L4 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCY M FACILITY ID TANK ID M [E�l L I I I I I I I I o D \ 1 3 1 © d Lo C�T_e')Tz_� CURRENT LOCAL AGENCY FACILITY FACILITY ID I APPROVED BY NAME PHONE 0 WITH AREA CODE 1A ty IIJ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNTbURCHARGE AMT. FEE CODE RECEIPTS BY; _l J ! , FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM 'A',UNLESS A t,-..;7ENT FORM W HAS BEEN FILED DATA PROCrSSIN1: 1`nov