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_ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM ,1 TANK TANK PERMIT APPLICATION INFORMATION �< COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACIi TANK. ,z 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 00 CF. aU FARM TANK-YES❑ NO (� li L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECT A is A. OWNERS TANK ID# B. MANUFACTURED BY: �� . C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (� I. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. j A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P LEUM B. C- ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRD CT ❑ 4 GASAHOL ❑5 JET FU L ❑ 6 AVIATION GAS :{ it ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ED<WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.t III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D 0 I A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SING WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ a ARY CONTAINMENT ❑99 OTHER I i ❑ 1 STEEL11RON Al STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ❑5 CONCRETE PGLYVI CHLORIDE, ❑ 7 AL M ❑8 100%MEMANOLCOMPATIBLEFRP i MATERIAL ; 9 BRONZE 0 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER - i C.INTIOR ❑ 1 RUBBE%LED 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEN NTNGINNING ❑5 GLASS ❑6 UNLINED UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER }. D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC j PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOV84 ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER OUND,BOTH IF APPLICABLE I i A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 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 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U '4 FIBERGLASS PIPE A U 91 NONE I C.MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD WlFRP A U 8 100%METHANOL COMPATIBLE FRP ; A U 9 GALVANIZED STEEL 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 1 VISUAL CHECK &>S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS i' P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST U7WY ► 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH r vim/ SUBSTANCE REMAININGGALLONS IN INERT MATERIAL? ❑YES E3 No I THIS FORM HAS BEE4 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 3 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDK TANK IDA ® O •� 010101 I CURRENT LOCA GENCY FACILITY iD 4 APPROVED BY AME PHONE 0 WITH AREA CODE /-- PERMIT PERMITC NUMBER PERMIT APPROVAL DATE [P�(MITEXPIRAP&DATE 1 CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: ir OFORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITYISITE APPLICATION, FORM 'A',UNLESS A 'OHRENT FORMA' HAS BEEN FILED