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STATE OF CALIFORNIA WATER RESOURCES CONTROI "OARD FORM B': UNDEhtiROUND STORAGE TANK PROt lsrAAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "!d MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED:30FApM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# icq� B. MANUFACTURED BY: 4� C. YEAR INSTALLED �/ D. TANK CAPACITY IMGALLONS' /0 (/D II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. V 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. G ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT p 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS VVV ❑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.# 64 C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A,D A TYPE Of i DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ff 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TANK ATEflIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDU NG ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING V6 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 T ROR ASPHALT ❑ 3 VINYL WRAP F-14 FIBERGLASSREINFORCEDPLASTIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 RECONCILIATIONP 8 3 VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAS USED(MO/YR) 2. ESTIMATED OU NTITY OF 3.WAS TANK EI EO WITH SUBSTA ING IN INERT T ❑yES NO GALLONS THIS FORM HAS EEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDG , IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® Q� U ©I 13 al FT CURRENT LgCAL AGENCYFACILITY ID# APP DBT,IfA � PHONE#WITH AREA CODE PERMIT NUMBER U PERMIT APPROVAL DATE ` ERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT - SURCHARGE AMT. FEE CODE -'RECEIPT# BY: -v S FORM B(a7-ee) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HAS BEEN FILED 4G COPY