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TRWATER RESOURCES CONi ^` STATE OF CALIFORI� ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM .gym TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑3 RENEWAL PERMIT E]8 TANK REMOVED MARK ONLY ❑ ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM ❑ 21NTEPIM PERMIT FARMTANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY PE 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,COMPLETE ITEM D. 2 LEADED ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 PRODUCT F] 4 GASAHOL E] 5 JET FUEL E]6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL El 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE El D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.# HAZARDOUS SUBSTANCE STORED 8,C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S,D ❑ 95 UNKNOWN ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER A.TYPE OF p SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER SYSTEM F-1 ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS [:] 4 STEEL CLAD WIFIBEAGLASS REINFORCED PLASTIC ❑ I STEEUIRON B.TANK F-1 5 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM El 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 7 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ 6 UNLINED a 95 UNKNOWN F-1 IS LINING LINING LINING ❑ 5 CI ❑ G MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION El91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV- PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDDERGROURNAD,BOTH IF APPLICABLE NONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A u 1 sucnoN A u z PRESS HE B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U ,95 UNKNOWN A U 99 OTHER A U ISTEEL/IRON A U 2 STAINLESSSTEEL A U 7 PPOLYVINYL CHLORIDE(PVC) p U 6FIBERGLASS PIPE 00 %METHANOLGOMPAU91 IBLE FRONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE 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 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VNDNEE WELLS P S 4 EU CTRONI MONITOR PP S 559GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7PRESSURE TESTING V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE B wASTANKHueowlrH 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. ATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION � AGE FACILITY ID# TANK ID# mAPPROVED BY NAME PHONE R WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID p PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PEflMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT BY: FORM a(6-29-661 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RRENT FORMA' HAS BEEN FILED FILE COPY