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i , I A I t Ur UALII-UHN6,,, WATER RESOURCES CONTRCoeSOARD =• FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT Ef5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 nTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARVTANKCLOSURE � ❑ ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �O FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 10 A. OWNERS TANK IDM B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �J6T II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. � A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ i PRppUpT ❑4 GASAHOL ❑5 JEf FUEL ❑ 6 AVIATION GAS _-]5 HAZARDOUS ❑60 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 6 CA.&R C.A.S.A. .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOLE A.B,C.A D A TYPE OF ❑ I OOLIBEWALLED ❑3 SINGLE WALLED WITH EXT94OR LINER F-195 UNKNOWN SYSTEM ❑2 SINGLE WALIED ❑4 SECONDNN CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGUSS ❑ 4 S UL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MANE ❑ MATERIAL5 CONCRETE [-]6 POLYVINYL 0(LEIRDE F-] 7 ALUMINUM ❑B 1011%METHANOL COMPATIBLE FRP ❑ ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL [-]95 UNKNOWN 99 OTHER C.INTERIOR F-1RUB 1 BEAUNED ❑ 2 ALKYD LINING F13 EPDXY UNING ❑4 PHENOUCLNING LINING ❑5 GUSSUNING ❑64XLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE NTH I00%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAA OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 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 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 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 C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 6 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 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ElYES E] 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 A SIGNATURE) DATF LOCAL AGENCY USE ONLY COUNTY K JURISDICTION W AGENCY R FACILITY ID R TANK ID W / I 3 CURRENT LOCAL AOENCY FACLLITY ID s APPROVED BY NAME (-� PHONE 0 WITH AREA CODE �) ////Z Z./S 6 PERMIT NUMBER PERMR APPROVAL DATE PERMIT EXPIRATION DATE CHECKF PERMIT AMOUNT 'RCHARGE AMT. FEE CODE F WTI FORM B(3-7.88) THIS FORM MUST BE ACCOMPANIED BY A FACILTTY/SITE APPLICATION, FORM 'A',UNLESS A CURREE Y FORM•A• HAS BEEN FILED