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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD _ FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �` -' '6- TANK TANK PERMIT APPLICATION INFORMATION „j COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL K 1 C) ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / ZI FACILITY/SITE NAME WHERE TANK IS INSTALLED: SU ON I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# OI B. MANUFACTURED BY: C. YEAR INSTALLED U4.*- I D. TANK CAPACITY IN GALLONS: y,� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 7 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL El�l pRODU� ❑4 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 8 C.A.S.# CAS.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,8 D A. TYPE OF ❑ I OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81D0%MUHANOLCOMPATIBLEFRP MATERIAL -0 9 BRONZE ❑ 10 GALVANIZED STEEL ff95 UNKNOWN ❑99 OTHER. C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING F-16 UNLINED IJ 96 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑�3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE U 96 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 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A Mt UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPAT18LE FRP A U 9 GALVANIZED STEEL A15 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. /JD P S VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTI-i CLOSED IN PLACE ' 1.ESTIMATD DATE LAST USED(MO/YR) 2. ESTIMAT QUANTITY OF 3.WAS TA KFILLED WITH SUBS EMAINING IN INET RIAL? [_-]YES ❑ NO OALLON8 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE CE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# FACILITY ID# TANK ID 8 3i oa1 1 1 1 101 ) CURRENT LOCAL AGENCY FACILITY ID# APPgOyED BYN E PHONE p WITH AREA CODE {/yJIJL/� 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29 IIS) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AMORENT FORMA' HAS BEEN FILED DATA PROCESSING COPY