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STATE F CALIFORNIA WATER RESOURCES CONTROL BOARD •„„ FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION `- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.. �,,,,a '• MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY ANK #b ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVE' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY QO A A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED d D. TANK CAPACITY IN GALLONS: II, TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPLETE ITEM D. . A. i MbTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL - ❑3 CHEMICAL PRODUCT ❑ 4 OIL �1 PRODUCT E]4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS i ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ff 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TANK 1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS.REINFORCEDPLASTIC . B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IN%METHANOLOOMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING dUNLINED I ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC a PROTECTION [-]5 CATHODIC PROTECTION E]9! NONE I- 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 1 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A V 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FAP A U B 1 W%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6 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. Vf P S 1 VISUAL CHECK P S 2 INVENTOR`(RECONCILIATION ' P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P B 7 PRESSURE TESTING nAwlfil NONE P B 95 UNKNOWN P 8 99 OTHER - } VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEP OVANTITY OF I XANK FILLED WITH SUBST E EMAINING IN MATERIAL'S [::]YES ❑NO � 4” I Jj GALLONS ,( THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER, AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CQRRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) I` DATE' LOCAL AGENCY USE ONLY ,f IPERMIT UNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ___ '� od 6 w OdD . . ..1 T LOCAL A¢ENCY CILITY ID N APPROVED BY N E�� PNONE li YYITH AREA COOK UMBERPERMIT APPROVAL DATE P RMIT EXPIR TION DATE PERIMIt AMOUNT URCHAROE AMT. FEE CODE RECEIPT N Y. - - FORM 8(6-29-86} THIS FORM MUST BE ACCOMPANIED lWWPAC(UTY/SRE APPLICATION, FORM `A',UNLESS A ENT FORM`N HAS BEEN FILED I IATA PQ0CecRlulr^vv n