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STATE OF CALIFORNIA WATER RESOURCES CONTROI ^OARD FORM 'B': UNDERGROUND STORAGE TANK PROCMAM TANK TANK PERMIT APPLICATION INFORMATIONm iu+ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE E:18 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: y ft 0 FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC A. OWNERS TANK ID# OI 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0� GL1 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. ❑ 1 UNLEADED ❑2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 6 JEF FUEL ❑ .,AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESFRIBE Iq Am D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM `ZSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCHEIE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METRANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 DUNWG F-13 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING &kfUNUNED ❑95 UNKNOWN "Al ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE V295 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 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 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1W%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A5 UNKNOWN A U 99 OTHER V. LEAK DETECTION STEM CIRCLE R FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING 9 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TAVK FILLED WITH S E REMAINING IN INET A RIAL? ❑YES [:] NO GALLONS j THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOkEbGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 � 40 1 (- -z- I I I I ao 1 o CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY NAME PHONE#WITH AREA CODE r PERMIT NUMBER PERMIT APPROVAL DW PERMIT EXPIRATION DATE i CHECK# PERMIT AMOUNT SURC11ARGE AMT? 0. FEE CODE j-RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPAftO BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE URRENT FORM'A' HAS BEEN FILED