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------------- STATE OF CALIFORNI WATER RESOURCESCONTRf 30ARD ; `` UNDERGROUND STORAGE TANK PROMAM � FORM `B': TANK PERMIT APPLICATION INFORMATION Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. N 1 O 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑8 TANK REMOVED ' t w MARK ONLY ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ONE EM ❑ 21NTERIM PERMIT FARMTANK-YES❑ NO N 10 In A CD FACILITY/SITE NAME WHERE TANK IS INSTALLED: (A 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBE MANUFACTURED BY FY A. OWNERS TANK IDN D. TANK CAPACITY IN GALLONS'. C. YEAR INSTALLED 11. TANK CONTENTS IF(A.1),15 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM ❑ 3 DIESEL B C. E] E] 2 1 UNLEADED 2 LEADED A. E] 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑❑ 1 PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 113 CHEMICAL PRODUCT [:] 4 OIL 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN Q WASTE 11J D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � C.A.S.N' HAZARDOUS SUBSTANCE STORED&CA S,N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 95 UNKNOWN A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC F-] B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED ffin UNKNOWN to LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO HER D.CORROSION ❑ 1 POLYETHLENEWRAP F-12 TAR OR ASPHALT ❑3 VINYLWRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE5 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 U UNKNOWN A U 99 OTHER A B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U UNK<OWN 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VACOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 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 ❑NO THIS FO AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY I�USE I�ONLY -�I CON JURISDICTION#L- -U--�-�J AGE FACILITY ID k TANK IDD (� a 3 cp U CURRENT LOCAL AGENCY FACILITY IDN APPROVED YNAME PHONE N WITH AREA CODE 0 PERMIT NUMBER PERMITA#'PIIOVAL DATE PERMIT EXPIRATION DATE CNECKN "RUM AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCONPA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS..I FORM W HAS BEEN FILED DATA-P$QCESSING COPY