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STATE O.F,'CALIF0RN1_ WATER RESOURCES CONTR _BOARD FORM 'B'' UNDERGROUND STORAGE TANK PROGRAM TANK [JJ� TANK PERMIT APPLICATION INFORMATION 1. ' 'LCOMPLETE A SEPARATE FORM WITH THE FOLLOWING2±ORMATION FOR EACH TANK. z 10 I MARK ONLY ❑ I NEW PERMIT . ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P ENTLY C ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ K AMENDED PERMIT. ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVE O CJJ FACILITY/61TE NAME WHERE TANK IS INSTALLED: 7�/Sti1 2 FARM TANK•YES❑ NO (V I. TANK DESCRIPTION COMPLETEA TEMS•IFUNKNOWN—SO SPECIFY CO A OWNERS TANK IDM A ILVd O B. MANUFACTURED BY: Ca C.YEA INSTALLED f q SV 0. TANK CAPACITY IN GALLONS: II. TAN CONTENTS IF(AL1),19 MARKED,COMPLETE ITEM C.IF( Y),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 171 UNLEADED ❑ 2 LEADED IESEL ❑ 3 CHEMICAL PRODUCT ❑{OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 50 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.M CAS.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,i D A.TYPE OF ❑I DOUBLEWNlED ❑ 3 SINGLE WALLED WITH EXTEROR UNER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 1 SECONDARY CONTAINMENT ❑ 99 OTHER . ❑ I STEEULnON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑6 STEEL CIAO WIRBERGLASS REINFORCED PLASTIC B.TANK CRETE 6 POLYVINYL al 7 ALUMINUM MATERIAI:, 5 CON MM;❑ ❑ ❑ ❑8100%1AETIIANOL COMPATIBLE FRP '.,; . ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBSERUNED 2 ALILYO LINING ❑3 EPDXY UNING ❑4%IEWXCUNING LINING :❑ 5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COWATIBLE WITH IW%METHANOL7 [:]YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAOORASMAIT ❑3 VINYLWRAP ❑6 FIBERGLASS REINFORCED KASTIC PROTECTION ❑ 5 CATIDDICPROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEOTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U H FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADVI A U B 100%METHANOLCOLIPATI8LEFRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECQNDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 9 1 VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P 9 3 VADOSE WELLS P 9 / ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P 9 6 PRECISION TESTING P 9 7 PRESSURE TESTING P 9 91 NONE P B 95 UNKNOWN P 9 99 OTHER Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) :I ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH - - SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF All KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID M TANK ID M CUflflENT LOCAL AGENCY F ILITY 10 9 - APPROVED BY NAPE PHONE M WITH AREA CODE GG PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE \U CHECK PE RMITAMOUNT SURCHARGE AMT. FEE CODE ECEIPTF L all .� s FORM B(6.29.86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS CURRENT FORMA' HAS RFFM FII FD