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�,..Y,,.rxn#.r"'#'T•VFP1FyP" . ..1 .y1 Y.` STATE OF CALIFORN[A WATER RESOURCES CONTRO' BOARD FORM 'B': UNDOW6ROUND STORAGE TANK PROGL� R11AM � .. TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT 3RENEWAL PERMIT 5 CHANGE OF INFORMATION MARK ONLY . . ❑ ❑ 7 PERMANENTLY CLOSED TANK 10❑ ONE ITEM ❑2INTERIM PERMIT ➢ ❑ 4 AMENDED PERMIT ❑67EMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INS199ALLED: FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Cn T A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTEN IF(A.1),IS MARKED,COMP= ITEM C.IF(A7),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 ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EM ❑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 CO STRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON 2 STAINLESS WE ❑ 3 FIBERGLASS M 4 FEEL CLAD W/RBERGLASR REINFORCED PLASTIC B. TANK F-�5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR E] 1 RUBBER UNED [:j2 AM UNING ❑ XYUNING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS UNNG MATERIAL COMPATIBLE WITH 10M METHANOL? ❑Y%ES D. CORROSION ❑ 1 POLYEIHLENE WRAP ❑ 2 TAR 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 ALU)3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTIONU 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 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A B 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. Ps 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTIN P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED PATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF &WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES [_—] NO T.141'S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICA M TED&SI RE) DAT LOCALEN O I wf LINTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 4 WITH AREA CODE G PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk FORM e r6 29-eel THIS FORM MUST BE ACCOMPANIE�f A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FM.ED DATA PROCESSING COPY