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STATE OF CALIFORNI! WATER RESOURCES CONTRO' OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m �' 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 PERMANENTLY CLOSED TAN 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ❑ NO FARM TANK-YES FACILITY/SITE NAME WHERE TANK IS INSTALLED: fV IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN I I B. MANUFACTURED BY: 'n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: LP QO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 L ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NA E OF HAZARDOUS SUBSTANCE STORED&CAS. C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 INGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 DARE CONTAINMENT ❑99 OTHER ❑1 STEBUIRON ❑2 STAI STEEL ❑3 FIBERGLASS ❑4 STEELCIADW/RBERGLASSREINFONCEDRASTIC B. TANK ❑5 CONOETE ❑6 POLYPI CHLORIDE ❑7 ALUMINUM ❑8 189%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑18 GALVANI STER ❑95 UNKNOWN ❑99 OTHER ❑i RIBBER UNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 P9ENOLICUNING C.INTERIOR ❑5 GLASS LINING F-1 6 UNUNED ❑95 UNKNOWN LINING ❑ IS UNING MATERALCOMPARBLEWITH 1W%METHANOL? [:]YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASSREINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF NDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE VU3 TY A U 91 NONE A U 95 UNKNOWN A U 99OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL INYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN ER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SEC? ARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S UNKNOWN P & 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY x FACILITY ID N TANK ID M = oo ff= ora i CUR RE T LOCAL AGENCY FACILITY IDN APPROVE BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA MIT EXPIRATION DATE CHECKN PERMIT AMOUNT - SURCHARGE AMT. FEE CODE I RECEIPT• BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',uxLESSA R M W HAS BEEN BLED DATA PROCESSING COPY __