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STATE OF CALIFORNWATER RESOURCES CONTR 30ARD FORM `B': UNDtAGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COf LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLO NK ONE ITEM F-12 INTERIM PERMIT F-14 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -7 0 F M TANK-YES FPrNo ❑ O 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDR B. MANUFACTURED BY: VP W C. YEAR INSTA D D. TANK CAPACITY IN GALLONS: II. TANK qdNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A. ,IS NOT MARKEDJ06MPLETE ITEM D. N A 1 Mo OR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 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.N C.A.S.q: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A.TYPE OF DOU�WALLED ❑3 SNGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIRE ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE LuMINUM ❑8100%METHANOL COMPATIBLE FRP , ❑9 BRONZE ❑ 10 GALVANIZED ML 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING I!� LINING ❑5 GLASS LINING ❑6 UNLINEDNOWN F-1ISUNING MATERIALGOMPATIBLEWTTH 100%METHANOL? ❑YES ❑ NO 990THER D. CORROSION ❑ 1 POLYERILENEWRAP ❑2TAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER ` j 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 U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i 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 A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. L#AK 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 P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS NP 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER A. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑yES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCYS FACILITY IDR TANK ID R y � da CURRENT LOCAL A CY FACILITY ID k APPROVED B E PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKM PERMIT AMOUNT SURCHARGE ANT. FEECODE RECEIPT By- FORM a(5-29-93) THIS FORM MUST BE ACCOMPANIED BY A AGILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FlLED DATA PROCESSING COPY