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nom, STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM :mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ i NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PER ANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 16 3 FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: IV C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' Q 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 2 PETROLEUM B. C. ❑ i UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑fi 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&C.A.S.R CA.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A.TYPE OF ❑ 1LE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE ❑4 SECONDARYCONTAINMENT ❑99 OTHER j ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE fi POLWINYL CHLORIDE ❑ 7 ALUMINUM ❑B 10016 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F--] I RUBBER LINED ❑2 ALKYD ❑3 EPDXY LINING ❑4 PHENOUC LINING ! LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEIHLENE WRAP ❑ 2TAR OR ASPHALT ❑3 V RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFA13OVE GROUND, U IF UNDERGROUND,BO7 APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 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 9 NE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE PVC) A 4 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 ETHANOL 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. ELlpq11 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS !I P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF011LLON8 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ONO 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# TANK ID# / 5 6O 7 CURRENOCAL AGENCY FACILITY ID N APPROVEO BYNAE�j PHONE N WITH AREA CODE D d'Zl a I PERMIT NUMBER PERMIT APPROVAL DATE ERYIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST SE ACCOMPANIED 81TA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUAIiENT FORMA' HAS BEEN FILED !!