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STATE OF CALIFORM WATER RESOURCESCONTR( 30ARD FORM 'B':UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑I NEW PERMIT ❑ 3 RENEWAL PERMIT Z81CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK IC ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 FARM TANK - YES ❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SP IFY A I-� A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED p),/`�/ D. TANK CAPACITY IN GALLONS II. TANK C04TENTS IF (A.11. IS MARKED. COMPLETE ITEM C- IF (A.11. IS NOT MARKED_ COMPLETE ITEM Ill / 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 8 D v A. TYPE OF A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED 3 DIESEL SYSTEM 2 SINGLE WALLED ❑ 3 CHEMICAL PRODUCT ❑ /OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN REM D, BELOW) ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF ❑ B 100%METHANOI COMPATIBLE FRP U 3 LINED TRENCH A U HAZARDOUS SUBSTANCE STORED & C.A.S. N41zzl�C.A.S. #: ❑ 10 GALVANIZEDSTEEL 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 8 D v A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMEI4T ❑ 99 OTHER 91 NONE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 A UM ❑ B 100%METHANOI COMPATIBLE FRP U 3 LINED TRENCH A U ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 41 LINING LINING F-15 GLASS LINING ❑ 6 UNUNED LEAK DETECTION SYSTEM nacl F D FnP PPHAAIW no c FnR NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑ YES NO ❑ 99 OTHER D. CORROSION F-11 POLYEIHLFNE WRAP ❑ 2 TAR Ofl ASPHALT [:] 3 A WRAP ❑ 4 HBMGLASS REINFORCE) PLASTIC PROTECTION [:1 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCIF A IF AROVF ORDIINn U IF I IMDFPQRnl Wn RnTU IV.PPI I I.R.. IA A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U9 NKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NO A U UNKNOWN A U 99 OTHER C. MATERIAL A A A U 1 STEEL/IRON U 5 ALUMINUMONCRETE U 9 GALVANIZED STE A A U U 2 STAINLESSSTEEL 9 NKNOWN A A A U 3 POLYVINYL CHLORIDE (PVC) A T U U 7 STEEL CD W/FAP A U U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE S 100% METHANOL COMPATIBLE FRP LEAK DETECTION SYSTEM nacl F D FnP PPHAAIW no c FnR P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P CTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8NKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACP 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ENO THIS F( Tm nnO MCCIV UUMVI-t I CU UNUtH VENAL I Y OF I-EHJUHY, AND I U 71 BEST OF A4Y KNOWLEDGE, IS TRUE AND Cl APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE 3RECT. LULJAL A4atNL:Y USG UNLY COUNTY N JURISDICTION # AGENCY R FACILITY ID # TANK ID # aE = = I I I/ F, 3 el; CURRENT LOCAL AGENCY FACILITY ID n APPROVED BY NAME PHONE # WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE I CHECK# I PERMITAMOUNT I SURCHARGE AMT. -ORM B (6-29 s6( THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, UA 1 A rNUcesslNu CUPY DATE RECEIPT # FORMA' HAS BE 14 FIL