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STATE OF CALIFOA WATER RESOURCES CONSPL BOARD FORM `B': U ERGROUND STORAGE TANK PROGRAM m mo TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑3 RENEWAL PERMIT ANK REMOVED MARK ONLY ❑ ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE W ONE ITEM ❑ 21NTERIM PERMIT FARM TANK-YES❑ NO I"J. FACILITY/SITE NAME WHERE TANK IS INSTALLED: N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D•LEADED ❑ 3 DIESEL B. A.�3 CHEMICAL VEHICLE FUEL ❑ 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL .0 � W 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 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.4 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D NKNOWN 1 DOUBLEWALLED ❑3 SINGLEWALLEDWNH DRERIORUNER A TYPE OF ❑q SECONDARY COMAINMENT ❑99 OTHER SYSTEM ❑ 2SINGLE WALED L ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL WUNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYOUNING 3 EPDXY UNING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED E05 UNKNOWN LINING ❑ )SEINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F-1 NO 990THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 NNYLWPAP ❑4 FI ERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U : NONE A 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 1 STEEL/IRON A U 2 STAINLESS STEEL A STEELINYL CLAD W/O PDE (PVC) A U 81 0%METHANOLFIBERGLASS PE COMPATIBLE RPNE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U OTHER A U 9 GALVANIZED STEEL A U 95 UNKNOWN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P S 21NVENTORYRECONC91 NONE ILIATION P S 3VADOSE WELLS P S 4EUNTRONI MONITOR P S 5 GOTHRD WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING ZZL VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLEDWITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? [:]YES ❑ NO 1.ESTIMATED DATE LAST USED(MO/Yfl) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL W TE EDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY IDM TANK ID# PPROVED Byyg1-1 � PHONEk WITH AREA CODE CURRENT LOCAL AGENCY FACILI #�r / . '/✓/ f/ E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMA' HAS BEEN FILED FORM 8(6-29-8B) THIS FORM MUST BE ACCOMPANIEY A FACILITY/DSIATTAPPROCIION, FONG OOP A',UNLESS U B