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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �m TANK PERMIT APPLICATION INFORMATION ro �� Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. 10 NL1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED K EM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED w U S 'AlC FARM TANK-YES NO (a [FA;CILITY/SITE;NA;MEEHERE TANK IS INSTALLED: O (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID R B. MANUFACTURED BY: Co C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3 0O II. TANK ONTEN7S IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. A. 1 MOTORVEHICLE FUEL 2 PETROLEUM B. G ❑ 1 UNLEADED 2LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL 5 JET FUEL `�6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER{DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER F-] 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER 1 STEBUIRON ❑2 STAIN SS STEEL- ❑"YRBERGNSS ❑4 STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC L TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8 1W%METHANOL COMPATIBLE RAP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY UNING 4 HENOUC LINING 7--- C. --C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑No 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 WILLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE VUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A i 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 IREDTRENCH A U 91„NONE "U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON AU Y STAINLESS STEEL A U 3 POLYVINYL CHLORME(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A J� 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. S IVISUALCHECK P S 21NVENTORY RECONCILIATION P 8 3VADOSE WELLS. 0 S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE • P S 9¢ UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 IDN TANKID# N I av d od bo o z CURRENT LOCAL AGENCY FACILR'1�1[�# � � ^ APPROVED BY NAME a PHONE#WITH AREA CODE PERMIT NUMBER loo J{ PERMIT APPROVAL DATE PEEERRMIITT EXPIRATION DATE /z-Z,/41r CHECK# PERMIT AMOUNT .SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-89) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY ,-,_