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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD ; FORM `B': UNDE GROUND STORAGE TANK PR R ROH TANK TANK PERMIT APPLICATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. ""'�°" o MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE10 w ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT vv N FARM TANK-YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY f B. MANUFACTURED BY: A. OWNERS TANK ID X D. TANK CAPACITY IN GALLONS: C. YEARINSTALLED II. TANK CONTENTS 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 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 912 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.k: HAZARDOUS SUBSTANCE STORED&C.A.S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D E OUBLEWALlEO ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TEEUIRON ❑2 STAINLESS SFEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED FUSTIC ONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑8100%MErKANOL COMPATIBLE FRP RONZE ❑ 10 GALVANIZED STEEL �NKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING rENOLIC LINING C. INTERIOR ❑ 5 GLASSUNING ❑6 UNLINED Ev 95 UNKNOWN LINING F-1ISLINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT F-1 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]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 CA 5 UNKNOWN A U 99 OTHER OWN 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 UNKNA U A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 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 STE p L 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 3 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PREBSURE TESTING P S 91 NONE P S>5 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED OUANTITY OF 3. INE TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/VR) 2. SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY N JURISDICTION X AGENCY N FACILITY IDX TANK ID k 3 C OCAL AGENCY FACILITY ID X APPROVED BY NAM L� PHONE X WITH AREA CODE ,aS*1YN\\ b PERMIT IN PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1) CHECK kPERMIT AMOUNT U CHARGE AMT. FEE CODE C T X BY: Q `.J FORM B(6-29-8e) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY