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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Go FORM 'B': UNDERGROUND STORAGE TANK PROGRAMTANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 0 MARK ONLY Eg 1 NEW PERMIT F-13 RENEWAL PERMIT F]5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: A n o FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID# 0- e. MANUFACTURED BY: A C71 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' OO II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. EjZ'l MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. E] 1 UNLEADED 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT [-]4 OIL WIPRODUCT [:] 4 GASAHOL [:]5 JET FUEL ❑6 AVIATION GAS ❑ 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.# N04 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ©2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD 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 ❑ N OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 AUDD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHENE WRAP ❑2TAR OR ASPHALT ❑ 3 M WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE rC. STEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ONSTRUCTION A 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 A 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE ATERIAL AU 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B /00%METHANOL COMPATIBLE FRP A U 9 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. P 3 1 VISUAL CHECK 08 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS ` P PRECISIONTESTING P 8 7 PRESSURETES TING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.V A OALLONB ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH A 1 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO � F• THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 oo / l DOoI CURRENT LOCAL AGENCY FACILITY IDR AP R ED BY AME PHONE#WITH AREA CODE LCHECK# ' .� PERMIT APPROVAL DA PERMIT EXPIRATION DATE / v -7 iaa9 � a i6'PERMR AMOUNT SURCHARGE AMI. FEE CODE CEIPT# FORM B(6-29-33) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A- MRRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY