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STATE OF CALIFORN;_ WATER RESOURCES CONTR�BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPL A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 00 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Qc) FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY !C A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. EVrl MOTOR VEHICLE FUEL q [p PETROLEUMF<AS . C. ❑ 1 UNLEADED ❑2 LEADED, DIESEL µ ❑_3 CHEMICAL PflODUCT ❑ ROIL DUCT ❑4 GASAHOL 5 JEf FUEL L]6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY E] 95 UNKNOWNTE ❑'7 METFIANOL ❑99 OTHER(DESCRIBE IN ITEM/D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,F HAZARDOUS SUBSTANCE STORED&CA.S.N C.A.S.N: �V XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A. TYPE OF ❑ 1 EWAUED ❑3 SINGLE ALLEDWRH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEELARON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A QV95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 I VISUAL CHECK o6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 9 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(M /YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH /v AI / SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID# TANK ID# lo O C� I I UC> I O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE L i A// A PERMIT NUMBER PERMITAPPROVAL DATE P IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FOPn B I3-7 88i THIS FORM MUST BE ACCOLU-097A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-r%RENT FORMA' HAS BEEN FILED -