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STATE„OF. CALIFORNif, WATER RESOURCES CONTR•BOARD FORM 'B' 1 UNDERGROUND STORAGE TANK PROGRAM 'T'ANK �� TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN 'INFORMATION FOR EACH TANK. ZI 10 MARK ONLY ❑ I NEW PERMIT. ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T NK j ONE ITEM 1 ❑2 INTERIM PERMIT ❑ <AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED c W ' FACILITY/SITE NAME WHERE TANK IS INSTALLED; (Jr�l � 7 FARM TANK•YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY O cc A. OWNERS TANK ID N ' B. MANUFACTURED BY: CO C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /000 II. TANK NTENTS 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 ❑ 1 OIL 1 Pfl000CT ❑ GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E]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.N C.A.S.H: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA.B,C.&D A TYPE OF - ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUTAON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK CHLORIDE 7 ALUMINUM WATERIAL, ��.;F7 ❑5 CONCRUE 6 POLYVINYL CHL ❑ ❑610D%LIETHANOLCOIAPARBLFfAP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 AUKYD LINING ❑ 3 EPDXY UNING ❑ N PHENOLICUNING LINING, ❑ S GLASS UNING ❑ 6 UNLINED ❑ 95 UNKNOWN '❑ IS UNING MATEAUI.COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1.POlYE7HLENE WARP ❑2 TAR OR ASPHALT ❑ 3 WWYLWRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 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 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A V 1 STEELIIRON A U 2 STAINLESS STEEL A V 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE 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 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCIUATION P 8 3 VADOSE WELLS P B I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PgECISION TESTING P 8 7 PRESSURE TESTING P B 91 NONE P 8 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 E]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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N Ll 10le-7171 I CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIONDATE -ZZ - CHECKF PERMIT AMOUNT SURCHARGEAMT. FEE CODE ECEIPTI BY; - . . FORM BIB-?9.061 THIS FORM YIIST AF 1CPnuoewcn ur.c.ru,�,�,.. .,.,..,...�..... r-i.•,.. ,., ... _._