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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAMgo FORM `B': TANK TANK PERMIT APPLICATION INFORMATION z ��COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ICD MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHAN:OFFORMATION fE;7,KfiMANENTLY CLONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPANK CLOSURE K REMOVED I D q` L. _IS/� K-YES❑ NO IN FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z Iv I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 B. MANUFACTURED BY: A. OWNERS TANK IDR D. TANK CAPACITY IN GALLONS: (' C. YEAR INSTALLED II. TANKfCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT B. MARKED 1 OMPPLOE DE ITEM D. LEADED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑ 5 HAZARDOUS ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D �I 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF I-,f 1 DOUBLE ❑ lrsJtl 4 SECONDARY CONTAINMENT ❑99 OTHER SYSTEM 2 NGLE WALLED ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXYUNING ❑,�414ENOUC LINING C. INTERIOR ❑6 UNLI ll�95 UNKNOWN F7LINING ❑ SGIASS LINING IS LINING MATERIAL COMPATIBLE WITH METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 6100%METHANOL COMPAFIBERGLASS PIPE A UIBLE FRP 91 C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 9 GALVANIZED STEEL 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. `( S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS IB1/1 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNONWTE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY IDR TANK ID# / � PNO®NWIT�REA CODE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PERMIT NUMBER (/'mow(, /d` 3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE RECEIPT# CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE /.��• RM (6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORMA' HAS BEEN FILED B �{` DATA PROCESSING COPY