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STATE OF CALIFORN11h WATER RESOURCES CONTR OARD ,d FORM `B': UNDE GROUND STORAGE TANK PRD AM E �a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. r• F®ate'" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 5 -} 7 ] FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: v{ - Il� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-^$O S CIFY A OWNERS TANK ID# B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: C16 0 C YEAR INSTALLED I1. TA�CONTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM LETS ITEM D. A. HICLE 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 ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Z METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS F—] 80 EMPTY D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF , CAS #: HAZARDOUS SUBSTANCE STORED&C.A.S.# /L- x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ t DOUB WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT [:] 99 OTHER ❑ 1 STEEL119ON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FI8ERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEELNKNOWN ❑99 OTHER El RUBBER LINE F-12 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR F-15 GLASS LINING F—] 6 UNLINED KNOWN LINING. ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE NKNCWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A UCTION 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 U 5 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK 3 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANI=NTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1. ESTIMAT€D DATE LAST USED{MplYRy SUBSTANCE REMAINING IN INERT MATERIAL? YES NO GALLONS 7Fi1S FORM FiAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TL7 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# Lo o cn1 CURRENT APPROVED BY NAME PHONE� #WITH AREA CODE LL AGENCY FACILITY ID# ✓�� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE W A FACILITYISITE APPLICATION, FORM 'A',UNLESS A! RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY