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STATE OF CALIFORNI4 WATER RESOURCES CONTR01 ARD p : FORM `B': UNDERGROUND STORAGE TANK PRONAM �o TANK PERMIT APPLICATION INFORMATION TANK L -C�dMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY LJ ' NEW PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF 4NFORMATION [-] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �� I ■ FACILITY/SITE NAME WHERE TANK IS INSTALLED: c FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY'. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Qa II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEWCLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BC EMPTY ❑ 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.# C.A.S.#: III. TANK CONSTRUCTION MA ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 LY VINYLCHLORIDE ❑ 7 ALUMINUM ❑ $1pQ%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 G VANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD KING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 11)0%METHA OL?' ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP F-1 2 TAR OR ASPHAL ❑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,lk 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-FRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPHON A U 2 STAINLESS STEEL NA U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIRFRGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE \AU 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FHP A U 9 GALVANIZED STEEL A U 95 UNKNOWN 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR S ONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 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 6 PRECIS'ON P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAC 1. ESTI 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 TH BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [M] I I = = I � [nb-Ti L6-16-F CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY ME PHONE#WtTH AREA CODE PERMI NUMBER PERM T PPR VA D PERMIT EXPIRATION DATE qD CHECK# PERMIT AMOUNT ^ RCHARGE MT. FEE CODE RECEIPT BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED 0-A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY