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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑15MAICNTLY CLOSED T 1 0 ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED P MIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO (Jl I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY w W A. OWNERS TANK ID q B. MANUFACTURED BY: w C. YEAR INSTALLED 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. CLE 2 LEADED 3 DIESEL A F-] 3 CHEMICAL PIRODUCTL ❑4 OILTROLEUM B. 1 PRODUCT C ❑4 GASAHOLUNLEADED E]5 JET FUEL E]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 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXAB,C,BD A TYPE OF ❑ I DOUBLE WALLED ❑3 SNGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN k SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER i ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81 OD%METHANOL COMPAT18LE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDG%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑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 i 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 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 S 7 PRESSURE TESTING 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 INEPT MATERIAL? YES 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N AGENCY M FACILITY ID R TANK ID M CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE 6oTE (D lb L PERMIT NUMBER PERMIT APPROVAL DATE OERMITEXPIRATI ATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT♦ BY FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED-NY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED ,S DATA PROCESSING COPY