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STATE OF CALIFORNP WATER RESOURCES CONTR' BOARD FORM B': UNDEfIGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY ❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK EO 1 NEW PERMIT �1 ONE ITEM 1:12 INTERIM PERMIT 1714 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑$-TANK REMOVED O—F FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FARM TANK-YES❑ NO ` N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY uj (D A. OWNERS TANK ID R -100a B. MANUFACTURED BY'. C. YEARINSTALLED - D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ET-i'PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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&C.A.S.A C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ 1 DGUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%MMMOLCOMPATI9LEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL,,E�T95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑5 GLASS LINING ❑6 UNLINED —�UNKNDWN ^ ❑ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO OTHER- LA N� D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE _29SGNKNOWN ❑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 UNKNOWN A U 99 OTHER " B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AQ 95JUNKNOWN A U MOTH A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 810M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL f_?_93 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P 8 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 PERJUR ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. " APPLICANT'S NAME(PINTEDBSIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION q AGENCY 4 FACILITY ID p TANK ID k CURRENT LOCAL AGENCY FACILITY IO NTO�� pppgOyED BYNAME I —� PHONE N WITH AREA CODE sq PERMIT NUMBER `J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE `/"(•(J\ n/ CHECK* PERMIT AMOUNT I SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(6-29-6q) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS7rCURRENT FORMA' HAS BEEN FILED DATA PROQ K,,SING COPY