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STATE OF CALIFORho WATER RESOURCES CONT BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TALK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED' (� , I. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # �� B. MANUFACTURED BY: C. YEAR INSTALLED A. SYSTEM TYPE II. TANK CONTENTS IF (A.1), IS AR A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETRO EL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 5 HAZARDOUS ❑ 80 EMPTY D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME HAZARDOUS SUBSTANCE STORED & C.A.S. # D. TANK CAPACITY IN GALLONS: 7 PE MANENTLY CLOSED TANK ❑`S TANK REMOVED FARM TANK - YES Lf NO COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. g C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) III. TANK CONSTRUCTION MARK ONE ITE ONLY IN BOX A, B, C,& D A. SYSTEM TYPE A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE ALLED WITH EXTERIOR LINER U 2 PRESSURE SYSTEM ❑ 2 SINGLE WALLED 4 SECONDA CONTAINMENT B. CONSTRUCTION ❑ 1 STEELIIRON ❑ 2 STAINLESS STE ❑ 3 FIBERGLASS U 2 DOUBLE WALLED B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLOA E ❑ 7 ALUMINUM MATERIAL ❑ 9 BRONZE ❑ 14 GALVANIZED STEEL ❑ 95 UNKNOWN A U 3 PO INYL CHLORIDE (PVC) A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING A C. INTERIOR LINING 5 GLASSUNING ❑ 6 UNLINED A U 7 STEEL LAD WIFRP k U 8 140°k METHANOL COMPATIBLE FRP ❑ 1SLININGMATERIALCOMPATIBLEWITHIW%METHANOL? ❑ S ❑ NO A D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2TARORASPHALT ❑ 3VI LWRAP U 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UN OWN C.A.S. M: ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC ❑ 8 100% METHANOL COM?ATI9LE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LIN6NG ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS REINFORCED PLASTIC ❑ N OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERG OUND, BOTH IF APPLICABLE V. LEAK DETECTION SYSTEMA CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A RIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILkATION P S 3 VADOSE WELLS P S 4 ELEC ONIC MONITOR P S 5 GR411N0 WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKN WN 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 # El 1 1 161616)Eoa 1�1-. CURRENT LOCAL AGENCY FACILTY IDM APPROVF D BY NAME °r'�%� PHONE M WITH AREA CODE I l � PERMIT NUMBER I PERMIT APPROVAL DATE f I' PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I + EIPT # I BY: FORM a (6-29-B8) THIS FORM MUST BE ACCOMPANIED BYE ITYISITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED DATA PROCESSING COPY O A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 RAVITY 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 LI ED 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 PO INYL 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 LAD WIFRP k U 8 140°k METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEMA CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A RIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILkATION P S 3 VADOSE WELLS P S 4 ELEC ONIC MONITOR P S 5 GR411N0 WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKN WN 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 # El 1 1 161616)Eoa 1�1-. CURRENT LOCAL AGENCY FACILTY IDM APPROVF D BY NAME °r'�%� PHONE M WITH AREA CODE I l � PERMIT NUMBER I PERMIT APPROVAL DATE f I' PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I + EIPT # I BY: FORM a (6-29-B8) THIS FORM MUST BE ACCOMPANIED BYE ITYISITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED DATA PROCESSING COPY O