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STATE,OF.'CALlFORNlA WATER RESOURCES CONTROL BOARD FORM 'B' UNDERGROUND STORAGE TANK PROGRAM TANKC' TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK _ MARK ONLY f.;.❑ I NEW PERMIT . ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 P El CLO 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: W .�� FARM TANK-YES❑ NO ❑ FV I. TANK DESCRIPTION COMPLETE ALL ITEMS•IFUNKNOWN-60SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A-1),16 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE REM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ I PRODUCT ❑ 1 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 S CAS.E CA.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A.TYPE OF ❑ I DOURLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑1 SECONDARY CONTAINMENT ❑99 OTHER 171 STEEUTAON ❑ 2 SIAINLESS STEEL ❑3 RBERGuM ❑ f STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL B.TANK IL ❑ 5 DDNCRETE ❑6 POLYWH%ORIDE I ALUMINUM ED 8 IW%I THMOLCOUPATIBLEFRP , � ❑ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 L9SANOWN ❑99 OTHER ❑ 1 RJBBERUNED ❑ 2 AULY.D UNING ❑ 3 EPOAYUNING ❑ 1 RIENOUCUNING C.LINING. ',❑ 5 GLASSUNING ❑6 UNUNED ❑ 95 LIN6NOWN -❑ ISUNINOVATERW-COLLPATIBUWRHIW%MMW40LI ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑/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 U 1 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 i 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 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL 'A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK - P 8 2 INVENTORY RECONCIUATION P 8 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [-]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION 8AGENCY 8 FACILITY ID 8 TANK ID S �Tn 2 qn / CURRENT LOCAL AGENCY FACILITY IDI G APPROVED BY NAME PHONE f WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK ,PERMIT AMOUNT SURCHARGE AY T. FEE CODE ECEIPT1 8Y: _ '.. FORMBI9-29-881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED