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STATE OF CALIFORN140 WATER RESOURCESCONTROOARD h •.• FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION1 f ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ , AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: . - / / , - �� ' FARM TANK-YES❑ NO I 0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. CA' A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM I C. ❑ 1 UNLEADED ❑2 LUDED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑A GASAHOL ❑ 5 JET FUEL [:]6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY [:] 95 UNKNOWN El WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D•BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY M BOX A B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED MTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT 99 OTHER ❑ I STEEUIRON ❑2 STNNLESSSTEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD WIFBEWAM REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE [:j6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑ B IDU%METHANOL COMPATIBLE FRP - ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 MOD LINING ❑3 EPDXYLINING ❑1 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL ODMPA11BLE WITH t00%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYErH-ENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑A 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 I 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U , FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE AU 7 STEEL CUD W/FRP A U B 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 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 9 3 VADOSE WELLS P S , ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P ! 91 NONE P N 95 UNKNOWN P S 99 GTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMAT(DOUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? EIYES ❑ 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 S SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN TANK ID M CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE 1Y PERMITNUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE �I 1 CNCCK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I Y. FORMS 19.29-88) THIS FORM MUST BE ACCOMPANIED B. CILITTISITE APPLICATION, FORM 'A',UNLESS A CUNHcNT FORMA' HAS BEEN FILED nATAI J