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STATE OF 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. _ _ Z IO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 1-1 7 RMANENTLYCL A ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED o / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0'L I NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-30 SPECIFY ~ A. OWNERS TANK ID II B. MANUFACTURED BY: Co C. YEAR INSTALLED i D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLNLDED ❑ETE ITEM D. A_ 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. 1 UEA2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 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 q HAZARDOUS SUBSTANCE STORED 8 C.A.S.# / 1 C.A.S.#: IV III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A. TYPE OF �❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH DGERIOR LINER ❑95 UNKNOWN SYSTEM LJ `SINGLEWALIED ❑4 SECONDARYOONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER I C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING [;�B`bNUNED ❑95 UNKNOWN' ❑IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO OTHER Iry D.CORROSION ❑ I POLYETHLENEWMP ❑2 TAR OR ASPHALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 6a/91 NONE ❑95 UNKNOWN ❑ 99 OTHER I IV. PIPING INFORM N CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTHIF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U j 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL At ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A C�J7��,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. y�A P S 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8.3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS NU P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 1 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTL LOSED IN PLACE 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMA D QUANTITY OF 3.WASTNK FILLED WITH SUBST GALLONS REMAINING IN IN TERIALI El YES E] NO THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [X 7 I I A a 10 CURRENT LOCAL AGENCY FACILITY ID x AP ROVED BY NAM PHONE#WITH AREA CODE l 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE f\ CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT x BY: V FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEnY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CIARENT FORMA' HAS BEEN FILED :IATA PROCESSING CC,-