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STATE OF CALIFORNI;_ WATER RESOURCES IOARD FORM 'B': UNDERGROUND STORAGE TANK PRO XtAM (a TANK ( TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 MARK ONLY ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FARM TANK-YES❑ NO rQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: IV I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP IFY A. OWNERS TANK ID p B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' Il. 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. NLEADED ❑2 LEADED ❑ 3 DIESEL [__j3 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 S C.A.S.# C.A.B.#: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA,B,C,&D A. TYPE OF1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM r�2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEELARON ❑2 STAINLESS STEEL F73 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. LINING TERIOR ❑5 GM UNING 6 UNUNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATI 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑�2 TAR OR ASPHALT ❑ 3 VINYLWIUP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 12-41 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AU 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 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 8 / VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 PRECISIONTESTING P S ] PRESSURE TESTING P S 91 NONE P S 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 FILLED 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. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY C�CO�UNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# `C-L_LJ CURRENT LO AL AGENCY FACILITY ID• APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: jam/ FORM B(6-29-BB) THIS FORM MUST BE ACCOMPAN,.0 BY A FACILITY/SITE APPLICATION, FORM 'A',UNLEStMRRENT FORMA' HAS BEEN FILLED OCESSING COPY