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STATE OF CALIFORN% WATER RESOURCES CONTR%ARD �—� �''. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ANK. TANK PERMIT APPLICATION INFORMATION �s r COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T TANK MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SBE MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMFP�LDETDE ITEM 2 B. LEADED ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL [:] 2 PETROLEUM ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.R. HAZARDOUS SUBSTANCE STORED&CA S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D ❑ 95 UNKNOWN ❑ 1DOUBLEWALLED E]3 SINGLE WALLED WITH EXTERIOR LINER A.TYPE OF INMENT ❑99 OTHER SYSTEM ❑ 4 SECONDARY CONTA 2 SINGLE WALLED ❑ ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANKEl8 100%METHANOL COMPATIBLE FRP ❑ 5 CONCRETE ❑fi POLYVINYLCHLORIDE ❑ 7 ALUMINUM MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 2 ALKYD LINING ❑ 3 EPOYY LINING ❑ 4 PHENOLIC LINING F-11 RUBBER LINED ❑ 95 UNKNOWN LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER El 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION F-1UNKNOWN 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-13 95 VINYLKNOWN 1:1 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLETY rvorvE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A,U 2 PRESSURE B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER U 91 NONE A .0!95 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBEHGLASBPIPE A U LE FRP NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE A U 9 GALVANIZED STEEL A U 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 S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 95ELECTRONIC UNKNOWN MONITOR P S 99GD WATER MONITORING WELLS OTHER P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE s WAS TArvK FILLED WITH2. ESTIMATED QUANTITY OF INERT MATERIAL? EYES [:] 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. TE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# FACILITY ID# COUNTY# JURISDICTION � AGE m APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECK M PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C #RENT FORMA' HAS BEEN FILED