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r STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 'V- 'H ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM �21NTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED Qa FACILITYYSITE NAME WHERE TANK IS INSTALLED: ' FARM TANK-YES❑ NO EiPl I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10' A. OWNERS TANK ID# B. MANUFACTURED BY: uir� C. YEAR INSTALLED (SCJ D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(0.1),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. I-•► I A. [jrl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL �' I ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 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.# /vA C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.B D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WAUID ❑4 SECONDARY CONTAINMENT ❑99 OTHER �STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 109%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR t RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNLINED UNKNOWN ❑B UNING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑NO ❑ 99 OTHER 0. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP LWRAP F-14 FIBERGLASS REINFORCED PLASDC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ERCuNKNDWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION Alp 1 SINGLE WALLED A U 2 DOUBLE WALLED A U3 LINED TRENCH A•U 95 UNKNOWN A U 99 OTHER A 01 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 6 100%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. PPA.S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.-ESTIMATED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# u I d 10 1 l 8 a O lo In I l CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY IYAMq PHONE#WITH AREA CODE -sm' PERMIT NUMBER PERMR APPROVAL DA PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT LSURCHARGEAIIIT. I FEE CODE RECEIPT# BY: FORM B(34-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATMN, FORM 'A',UNLESS AvTRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY