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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ;� `" TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN O ATION FOR EACH TANK. -- 10 10 MARK ONLY ❑ I N PERMIT ❑ 3 RENEWALPERMIT [ko?AZE OF INFORMATION ❑ 7 PERMANENTLY CLOS TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: r FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERS TANK ID W B. MANUFACTURED BY: '�77 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: l�V H. TANK CqNTENTS 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 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT F74 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS E]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.W C.A.S.W: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOU LE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SING ALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B. TANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 610A METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR1 RUBBERLINED ❑2 AM LINING ❑3 EPDXY LINING ❑ 4 PHE LINING LINING F-] 5 GLASS UNING F-]6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I OR MEMANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYEMIENE WRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV, PIPING INFORMATION 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 A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A a 91 NONE A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEELCLADW/FRP A U 8.100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS yY 6 PRECISION TESTING P S 7 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 USE (MO/YR) 2. ESTIMATED QUANTITY OF 3.WASTANKFILLEDWITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? EYES ❑ 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 I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID W TANK ID W EI o b I / SUI vO 16 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME NE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE qft PIRATIO TE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-2966) THIS FORM MUST BE ACCOMPANIEu§Y A FACILITY/SITE APPLICATION, FORM'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY