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STATE OF CALIFORNI! WATER RESOURCES CONTROL JARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM "q TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IIZ TANK O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM F-12 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W no FARM TANK-YES NO ❑ I—L FACILITY/SITE NAME WHERE TANK IS INSTALLED: NY -�� 00 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# I B]TANK URED BY: C.YEAR INSTALLED ya DCITY IN GALLONS: II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(AT),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL / ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTYUNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: Lac- HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLEWAUED ❑3 SINGLE WALED WITH EXTERIOR LINER UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS,,_-r=:] 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A ❑B 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE � 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYO LINING ❑3 EPDXY UNING ❑4 PHE C. INTERIOR ❑ 5 GLASS LINING F-16 UNLINED UNKNOWN LINING LINI ❑ ER IS LAMING MATERIAL COMPATIBLE NTH 1100%METHANOL? El YES ❑ NO [::] 99 OTHER D.CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE U 95 UNKN WN A> 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AA 6 A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNO N 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 S 1VISUAL CHECK P S 2 INVENTORY REGONCIUATION P S 3VADOSE WELLS P 8 4 ONITOR P S 5 GROUNDWATER MONITORING WELLS P S B PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOW P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) T2EESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY F Y# JURISDICTION# AGENCY# FACILITY ID# TANK ID# �AL A NCY F CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B I6-29-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY