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STATE OF CALIFORNIA WATER RESOURCES CONTROLIFRD u ' UNDERGROUND STORAGE TANK PROGRAM FORM `B': , ry Z ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. 1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL MARK ONLY ❑ 1 NEW PERMIT ❑ S ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / FARM TANK-YES NO N qs s N FACILITY/SITE NAME WHERE TANK IS IN SN O I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: A. OWNERS TA NK ID# D. TANK CAPACITY IN GALLONS: O Od C.YEAR INSTALLED II. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LEADED 3 DIESEL B. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL I ❑ 6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL LLLYYYJJJ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D ❑ 1�UBLE WALLED ❑ 3 SINGLE WALLED WITH DTERIOR LINER ❑95 UNKNOWN A.TYPE OF SYSTEM 2 SINGLEWAUED ❑4 SECONDARY CONTAINMEM ❑99 OTHER ❑ 1 STEELARON ❑ 2 STAINLESS STEEL ❑.3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL J5 UNKNOWN ❑N OTHER ECORROSIOW UBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING n 4IWENOUC LINING ❑6 UNLINED rum- / UNKNOWN GLASS UNINGUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER POLYETHLENEWRAP ❑2 TAR OR ASPHALT �NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASIIC CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE p U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 4 FIBERGLASS 7PIPE 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 U/96A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) R U 8100%MPAUIBLEFR131 ONE C. MATERIAL AU 5 ALUMINUM A lj�6 CONCRETE A U 7 STEELCLAD W/FRP A U 9 GALVANIZED STEEL A /' 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUND WATEP MONITORING WELLS /C P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? [:]YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) LOCAL AGENCY USE ONLY j:]Ej NK ID# COUNTY# JURISDICTION# AGENCY# D / FaE APPROVED BY NAREA CODECURRENT LOCAL AGENCY FA{:LLJjY ID,#�OPERMIT NUMBER /�'L1-Nw"/ PERMIT APPROVAL DATE Y: �2CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CO FORM B(6-29-SB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY