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STATE OF CALIFORNIWATER RESOURCES CONTRr- BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �u TANK TANK PERMIT APPLICATION INFORMATION e,ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES❑ NO O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED I n D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑.1'�NLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE Of [frl DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 MORON ❑2 STAINLESS STEEL ❑3 FIBERGLASS Ej]'tSTEEL CUD W/FIBEGUSS REINFORCED PLASTIC B. MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑81 DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNE I❑-y22AWN _ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUC LINING 5 GLASS NG C. INTERIOR �S LINING MATERIAL TERIAL COMPATIBLES WITH 100%METHANOL? ❑YES ❑ NO E]99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑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 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A 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. P3 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 3 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 1 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFOALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] NO i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) pATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# a3 :c CURRE LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE*WITH AREA CODE ,7r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE cio I� CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM B I5-29-99) THIS FORM MUST BE ACCOMPANIED-BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY