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y.a STATE OF CALIFORNIlb WATER RESOURCES CONTRCSOARD FORM 'B': UNDE GROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. TANK (j MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO NK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �G FARM TANK-YES❑ NO N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 V W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1, 'J A. OWNERS TANK ID# B. MANUFACTURED BY: OD C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (� 11. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1) IS NOT MARKED, MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑4 GASAHOL [:]5 JET FUEL ❑6 AVIATION GAS F-1 3 CHEMICAL PRODUCT F-1 4 OIL 1 PRODUCT 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) 115 HAZARDOUS [:] 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE V95 INUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4fHENOUC UNING G INTERIOR ❑5 GLASS UNING ❑6 UNUNB7 95 NOWN LINING ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ WL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION E:]91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPEA U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE U 95 UNKNOWN A U 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 5ALUMINUM A CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U A 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. 8 1VISUAL CHECK P S 21NVENTORYREC3NCIUATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S fi PRECISION TESTING P 8 ] PRESSURE TESTI NG P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ap / d 8 0 2 8� ;APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILI IDM ��PERMIT NUMBER IAV] PERMIT APPATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# B�D C o FORMB(6-29-13B) THIS FORM MUST BE ACCOMPANIfb BYAFACILITY/SDITE ATAPPR TION, OR DA',UNLESS A CURRENT FORMA' HAS BEEN FILED