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STATE OF CALIFORN WATER RESOURCES CONTR OARD FORM `B': UNDE GROUND STORAGE TANK PRORAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I C: ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1111:1 (V ARM TANK-YES❑ NO ❑ ,p I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED (� D. TANK CAPACITY IN GALLONS: II. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑1 UNLEADED LEADED E] 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASOHOL ❑5 JET FUEL ❑ fi 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 / HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ WE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM E]8 100%ME COMPATIBLE FRP ❑9 BRO ❑ 10 GALVANIZED STEEL ❑96 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNUNED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEfHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAPn 2 T6R'OR ASPHALT ❑S VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION L�/J�9911 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 89 OTHER Be CONSTRUCTION A U 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 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 ONCRETE A U 7 STEEL CLAD W/FRA A U 9 GALVANIZED STEEL A" A U B 100%METHANOL COMPATIBLE FRP 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P g 5 GROUND WATER MONITORING WELLS P(:$)!PRECISION TESTI# 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTJJ ED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? DYES ❑ NO THIS FORM HAg BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY F__mir7;_ JURISDICTION# AGENCY# FACILITY ID# �NK ID#_u_:�w IIDN APPROVED BY NAN � PHONE N WITH AREA CODE PERMIT APPROVAL DATE p MIT IpAT10N D PERMITAMOUNT SURCHARGE AMT. ' FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MOMPANIEMFA FACILITY/SITE APPLICAT , FORM 'A',UNLESS A LTHRENT FORMA HAS BEEN FILED r\\\ DATA PROCESSING COPY �s