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STATE OF CALIFOR 'U WATER RESOURCES CONT BOARD FORM B': UN RGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ED`5�CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: '/ ;1 ' ve /k FRAM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN $. MANUFACTURED BY' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ S MOTOR VEHICLE FUEL ❑[K�I`CIL ETROLEUM R. C. F-] 1 UNLEADED ❑ 2 LEADED E]3 DIESEL E] 3 CHEMICAL PRODUCT ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ B AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN Rr2 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.N C.A.S.N- I II. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELlIRON ❑TANK 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1H8ERGLASS REINFORCED PLASTIC B MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLONDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPAT18LE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER C. INTERIOR ❑ I RU68ER LINED ❑ 2 ALKYD LINING El EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ fi UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHCIOICPROTECTION ❑ 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 1 STEELIIRON A U 2 STAINLESS STEEL 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 W1FRP 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3..WAS TANK FILLED WITH 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION k AGENCY# FACILITY ID M TANK ID N 2- CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK i PERMIT AMOUNT SURCHARGE AMT. gY. FEE CODE RECEIPT II FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FAC,..IYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY