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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM =: o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT , ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 P MANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMD ❑6 TEMPORARY TANK CLOSURE g<TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4+ FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID B. MANUFACTURED BY: 64- C. YEAR INSTALLED /�, D. TANK CAPACITY IN GALLONS: O A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. I"# A_ r 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. . C. ❑ 1 UNLEADEDEL�f LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �pROL)UCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.#: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM Rj�2SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ER-l'STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 f,ONCRETE ❑6 POLYVINYLCHLORIDE. ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING ❑6 UNUNED VuNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH 100%MERUNOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLBIE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC - PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UlgruNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETEA U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9-GALVANIZED STEEL A 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 RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 60!l 1 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. GALLONS ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 14 SUBSTANCE REMAINING IN 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 0 P' TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAT PERMIT EXPIRATION DATE `\`V\'71 CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPAMED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HASBEENFILED DATA PROCESSING COPY