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STATE OF CALIFORNI$ WATER RESOURCES CONT BOARD ,A FORM `B': UNDERGROUND STORAGE TANK PROGRAM Ab TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ^- 1NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: •, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBM SPECIFY BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED LETE ITEM C.IF(A.1),IS NOT MCRKE❑D,COMEADEDE ITEM D. II. TANK CONTENTS IF(A.1),IS MARKED,COMP LEADED ❑ 3 DIESEL A. E] 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT F-14 OIL ❑ 1 PRODUCT ❑ 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.W HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF ❑ ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER SYSTEM F-12 SINGLE WALLED F-11 STEEL/IRON ❑ 2 STAINLESS STEEL El FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK F-15 CONCRETE Fl POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED El 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑6 UNLINED ❑ 95 UNKNOWN LINING El5 GLASS LINING 01IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER ❑ 2 TAR OR AS ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ 1 POLYETHLENE WRAP PROTECTION F-15 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ gg OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPALIUABL99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE77� 7GRAVITYB.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALTRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 p U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMONRYIC�LEAK ODETECTION SOYSTOEM MUST MONITORING WEDS p $ 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 11NONEP S 95 UNKNOWN P S 99 OTHER P S 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? (�Y ES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN 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) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION# AGENCY# FACILITY ID# mPHONE#WITH AREA CODE APPROVED BY NAME CURRENT LOCAL AGENCY FACILITY ID# PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER SURCHARGE AMT. FEE CODE RECEIPT# BY: CHECK# PERMIT AMOUNT FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLIC T O ,CFORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED