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t STATE OF"CALIFORN WATER RESOURCES CONTRc OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM m 11( TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITHI.THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT. 0915 CHANGE OF INFORMATION : ❑7 PERMANENTLYCLOSEDTAIVK ONE ITEM ❑2 INTERIM PERMIT: ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , i � FARM TANK-YES NO ❑ i FACILITY/SITE NAME WHERE TANK IS INSTALLED: _ IV .CO I. TANK DESCRIPTION COMPLETE!ALL IT'EMs-IF UNKNOWN-SO SPECIFY - i aOWNER�STANK ID# : � B. MANUFACTUREDBY:ALLED 0. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS[NARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED nLEADED ❑3 DIESEL ❑3 CHEMICALPRODUCT ❑ 4 OIL Ef1 PRODUCT ❑4 GASAHOL R'{{{ ///(5 JET FUEL ❑6 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&CA.S.8 CA.S.q: Ill. TANK CONSTRUCTION MARK ONE ITEM[ONLY IN BOX A.B,C,&D A.TYPE OF 1 BLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR UNH[ ❑95 UNKNOWN SYSTEM LA2 S1NGIE WAL ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESSSTEEL 3 FIBERGAS5 ❑4 MEELCLAD WIRBERGLASSREINFORCEDPLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL - ❑9.BRONZE ❑ 10 GALVANIZED STEEL ❑"95 UNKNOWN ❑ MOTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING C INTERIOR LINING 5 GLASS LINING ❑6 UNUNM ❑95 UNKNOWN " ❑ r1' ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETIILENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4'RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE ❑95 UNKNOWN ❑99 OTHER �V. 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 91 NONE A U 95 UNKNOWN A U 99 OTHER B 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 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U .4 FIBERGLASS PIPE .A U 91 NONE 14 �C.MATERIAL A U 5 ALUMINUM ' A U 6 CONCRETE A (A 7 STEEL CLAD W/FRP A U 8 1 DD%METHANOL COMPATIBLE FRP. � A U 9 GALVANIZED STEEL A.U 95 UNKNOWN A L 99 OTHER i 1 V." LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. E P- S�4 VISUAL CHECK . P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR' P S 5 GROUND WATER MONITORING WELLS ! ' P S 8 PREGSIONTESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTTTY OF3.WAS TANK FILLED WITH - _ SUBRALIONS STANCE REMAINING IN INERT MATERIAL? [:]YES ❑NO i ' THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT.. ` APPUCANTS NAME(PRINTED S SIGNATURE) DATE" r li LOCAL AGENCY USE ONLY COUNTY 1F JURISDICTION#I AGENCY# FACILITY ID ];; j ;> i x1 '71 1:::::Zl El ? CURRENT LOCAL AGENCY FACILITY ID i APPROVED BY - .x-.R o PERMIT NUMBERPERMIT APPROVAL.DATE .PERMIT E7(PIRATION DATE GNECK/ PERMIT AMOUNT SURCHARGE AMT.. FEE CODE RECEIPT R `UNLESS AL'GNENT FORM ANAS ��\�" �"