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STATE OF CALIFORN• WATER RESOURCES CONTR•BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM = TANK TANK PERMIT APPLICATION INFORMATION rim r COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. _ Z Ic MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION - ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 15 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( {{N FARM TANK-YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cil CAO A. OWNERS TANK ID B. MANUFACTURED BY: O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL � 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS El BO EMPTY 0 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.R C.A.S.If: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEELRRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TANK TERIAL ❑5 CONCREFE E]6 POLYVINYLCHLORIDE E] 7 ALUMINUM E] B 1W%METRANOLCOMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYDIJNING E] 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYERILENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑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 SYSTEM TYPE A U I 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. P 6 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [_-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M r JURISDICTION M I�GENCY# FACILITY ID M TANK ID N I I ► I qr 1 s 1 f� CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE I WITH AREA CODE WT= PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE AECEIPT0 B FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' MAS BEEN FILED DATA PROCESSING COPY