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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK R PROGRAM TANK PERMIT APPLICATION p. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK MARK ONLY 0 1 NEW PERMIT �3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED CI r FARMTANK-YES❑ NO �O FACILITY/SITE NAME WHERE TANK IS INSTALLED: Y G E 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: IN GALLONS: C.YEAR INSTALLED D. TANK CAPACITY O II II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �1 MOTOR VEHICLE KIEL � 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL 3 CHEMICALPRODUCT 4 OIL [] 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS TANK 5 HAZARDOUS 80 EMPTY 0 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.#: HAZARDOUS SUBSTANCE STORED A C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM Ej 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT [�] 99 OTHER 1 STESUIRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM E]810016 METHANOL COMPATIBLE FRP MATERIAL Ej 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBERUNFD ❑2 ALKYD LINING F-� 3 EPDXY UNING 4 PHENOLIC UNING C.INTERIOR 5 GLASS LINING F]6 UNUNED 95 UNKNOWN LINING IS LINING MATERMLCOMPATIBLE WITH 100%METF1ANOl? YES D NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPUCA13LE 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE 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 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 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 OF 3.WAS TANK FILLED WITH F� SUBSTANCE REMAINING INOALLONB INERT MATERIAL? YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE T PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM e 16.29-eel THIS FORM MUST BE ACCOMPARIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESVNCURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY