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STATE OF CALIFORN& WATER RESOURCES CONT ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING'NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CWSEO-T NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED iN FARM TANK-YES NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: r 00 .P I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O B. MANUFACTURED BY: Y�` 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. A. 1 MOTORVEHICLEIRODUCTL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D F F ❑ 1IDOUBLE WALLED ❑3 SINGLEWALLED WITH EXTERIOR LINER ❑95 UNKNOWN a2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FAP IAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 ENOLICUNING C. INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? [DYES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 RBEAGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E1,95 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 i U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A i U 2SINGLE 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 1 STEEL/IRON 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 S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A rU 5 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 lJ3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS (3r-11 P S 6 PRECISION TESTING-P 8 7 PRESSURE TEBTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANTS NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID#`` FCURRENTAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-BS) THIS FORM MUST BEACCOMPAN195 BY A FACILITY/SITE APPLICATION,COP ORM �A',UNLESS A RENT FORMA HAS BEEN FILED