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�G STATE OF CALIFORtO WATER RESOURCES CONTI*BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION +b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -. G 1 NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TAN I G MARK ONLY ❑ ❑ ❑ ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: S& , FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY "J A A. OWNERSTANK ID R B. MANUFACTURED BY: (JI C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q G � IL TANK CqNTENTS IF(A.1),13 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED LEAOEO E]3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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 8 CA.S.R C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF F-1-1 UBLEWALLB) ❑3 SINGLE WALLED WITH R7ERIOR LINER ❑95 UNKNOWN SYSTEM 2 SING'V WALLED 4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEL/IRON 7 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CIALIWIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AWMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 APO UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIOR LINING ❑5 GLASS UNING UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHAN0I7 YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 T RASPHALT ❑3 WNYLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A(Uo JUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A INGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. WAfP S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURE TESTING !Icl91 NO P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH Ci / SUBSTANCE REMAINING IN INERT MATERIAL? YES NO ( GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY R FACILITY ID N TANK ID M = = = i 1 CURRENT AL AGENCY FACILITY 0 APPROVED BY NAME _ PHONE N WITH AREA CODE PERMIT NUMB R NN PERMIT APPROVAL DATEPE117YR EXPIRATION DATE CNECKk PERMIT AMOUNT ASURCHARGE AML FEE CODE RECEIPTA BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED B A FACILRYISRE APPLICATION, FORM `A',UNLESS A CURiffNT FORMA' HAS BEEN FILED - - DATA PROCESSING COPY