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STATE OF CALIFORNF WATER RESOURCES CONTR' BOARD FORM 'B': UNDERGROUND STORAGE TANK PROrGRAM TANK TANK PERMIT APPLICATION INFORMATION `sy COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. R= G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 26 CHANGE OF INFORMATION E] 7 PERMANENTLYCLO K 10 ONE ITEM r__12 INTERIM PERMIT F-14 AMENDED PERMIT 116 TEMPORARY TANK CLOSURE [_]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: n FARM TANK-YES NO ❑ N 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY w A. OWNERS TANK ID# (__ B. MANUFACTURED BY: C. YEAR INSTALLED CA_44_Z_/ D. TANK CAPACITY IN GALLONS: 11. TANK PONTENTS IF(A.),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL 2 PETROLEUMC. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL F-1B 3 CHEMICAL PRODUCT ❑4 OIL 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&CAS.# A46 CA.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A. TYPE OF QXDOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM F42 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER i STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FHP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBBIUNED ❑2 [UNING F-13 EPDXY LINING E]4 PHENOLIC LINING / LINING ❑ 5 CUSS LINING 6 UNLINED ❑W6NKNOWN N� V ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ I POLYEIHIENE WRAP ❑2 TAR OR ASPHALT ❑3 VW WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORM N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S /00%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. A)DAG P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TES 1NG P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTIMAT DOUANTFTY OF 3. WAST NK FILLED WITH SUB T REMAINING IN 1 E ATERIAL? [:]YES ❑ NO GALLONS THIS F M HAS BEEN COMPLETED UNDER PENALTY 15F PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# S = = I ol o _> I (y I (-/ I 1010 k2 124 '7z7/ S AGENCY FACILITY ID# APPRPVED BY NAIjF. /•�L xie PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAITE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ,ORIA 8;6-29 m) THIS FORM MUST BE ACCOMPANIEDSY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY