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V STATE OF CALIFORNIA0 WATER RESOURCES CONTROL99ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM i TANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. �" 1 TANK O MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 8 TANK REMOVE /I 7 PERMANENTLY CLOS K ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE N �Z RM TA K-YES NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: N I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN—SO SPECIFY B. MANUFACTURED BY:U� A. OWNERS TANK ID S D. TANK CAPACITY IN GALLONS: ' C.YEAR INSTALLED H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ fi AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.k: HAZARDOUS SUBSTANCE STORED 8 C.A.S.S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN A.TYPE OF ❑ ❑ 99 OTHER SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ I STEELIIRON ❑2 STAINLESS STEEL —13 FIBERGLASS ❑4 STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 AL UM ❑S IM%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHE IC LINING C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAO OR ASPHALT ❑3 VINYL P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE NKNOWN ❑99 OTHER tj 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 5 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 A 95 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 23TAINLES3 STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP C.MATERIAL A U SAI A U 9 GALVANIZED STEEL U 5 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 1VISUAL CHECK P S 21NVENTORY RECONCILIATION P 8 3VADOSE WELLS P ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS p $ 8 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P t'15 UNKNOWN P $ 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH REAM SUBSTANCE REMAININGG IN GALLONS 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED N 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 8 SIGNATURE) LOCAL AGENCY USE ONLY y� AGENCY S FACILITY IDS TANK ID S COUNTYS JURISDICTION = APPROVED AME PMO WITH AREA CCOD/ � mCURRENT LOCAL AGENCY,FACI(.bTY 1p N�� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER / FEE CODE RECEIPT k II/,1V1// CHECKk PERMIT AMOUNT SURCHARGE AMT. (N L rule cnnu IIIIST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED