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STATE OF CALIFORNF WATER RESOURCESCONTR' BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK f TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 1 NEW MARK ONLY F-1W PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK I O ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT L6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS IN STALLED:a G FARM TANK-YES❑ NO ® N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-SO PECIFY (� A. OWNERS TANK ID# 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. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED OED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL ❑1 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 8 C.A.S.# CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM rryy��2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1II ,STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK5 ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL. ❑95 UNKNOWN ❑99 OTHER. _. ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. NT RIIOR ❑ 5 GLASS LINING 19 6 UNLINED ! ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL OOMPATIL 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ i POLYETHLBJE WRAP ❑2 TARORASPHALT ❑3 VNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION I NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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&A STEEL/IRON A U 2 STAINLESS STEEL 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 STEELCLADW/FRP A U 8 100%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 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 8 1 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLFD WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑NO 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) DATE LOCAL AGENCY USE ONLY C"OOU�NTY/% JURISDICTION# AGENCY# FACILITY IDN TANKIDN CURR OCAL AGENCY FACILITY ID## APPROVED BY NAME PHONE 0 WITH AREA COOK C/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /3/j7y^ CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: d FORM B B-29-BBI THIS FORM MUST BE ACCOMPA118)BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS a URRENT FORMA HAS BEEN FILED DATA PROCESSING COP'*