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STATE OF CALIFORNI WATER RESOURCES CONTRO' 'BOARD FORM 'B': UND0GROUND STORAGE TANK PROIGRAM TANK PERMIT APPLICATION INFORMATION TANK CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z to MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED K ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: r* FARM TANK-YES= NO Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK IDN B. MANUFACTURED BY: /� ~ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: lro D 0 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 ❑ ETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEA ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT �IL 1 PRODUCT ❑4 GASAHOL 5 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 4�a� t h�� HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.M: III. TANK CONSTRYCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 ER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS Eklr4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM F-] B 100%METHANOL COMPATIBLE EBR ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 P ENOLICUNING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED 95 WN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES E] NOEi2' OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3AW WRAP ❑4 FIBERGLASSREINFORCEDPUSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOA 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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP U S 100%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 $ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S ) VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS Po ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 9 I PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANKFILLED WITH SUBSTANCE REMAINING IN '1 GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH9 BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY I �/ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER (!' PERMIT APP OVAL TE� PERMIT EXPIRATION DATE \ CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT p BY: ' V FORM a(6-29-66) THIS FORM MUST BE ACCOMPANIBww'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A,.,NRENT FORMA' HAS BEEN FILED/ DATA PROCESSING COPY