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STATE OF CALIFORI0 WATER RESOURCES CONT�BOARD "`•" FORM `B': UNDERGROUND STORAGE TANK PR GRAM ` m" TANK TANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "" 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 g8 TANK REMOVED p9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 7 W I 1�(( B. A. OWNERS TANK ID# �,[`i A vU��` MANUFACTURED 1' C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I II. 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY 95 UNKNOWN 2 WASTE ❑7 METHANOL [w'9(J OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 0,6 m 1 K m "T<I-4 04 34V L,2 cta 143 HAZARDOUSSUBSTANCESTORED&C.A.S.# #trollcum- 1QL10•a.13 n(ckk-_14`EO Ciao' g #: 5u'�"�Lu„�en ,,,-1 z 50 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,h D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 095 UNKNOWN � ,� SYSTEM ❑2 SINGLEWAUED F-14 SECONDARYGONTAINMENT x99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL E-13 FIBERGLASS ❑4 STEELCLAOW/FIBERGLASS REINFORCED PLASTIC B.TANK 5,CONCRETE F-16 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6160%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIORF75 GLASS LINING �6 UNUNED ❑95 UNKNOWN LINING F-1IS LINING MATERIAL COMPATIBLE WITH 10096 METFIANOL? ❑YES [:]NO [7—Q9 OTHER 11 11 y D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION I NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 9 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 95 NKNOWN 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 'Co A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOW 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 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VAD WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 8 9 NONE P S 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o0 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAMEPHONE#WITH AREA CODE ,c - PERMIT NUMBER .PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-SB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS WURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY