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STATE OF CALIFORNI WATER RESOURCES CONTRf BOARD FORM 'B': UNDERGROUND STORAGE TANK PRO-GRAM S ." TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY zf, NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 21NTERIMPERMIT F-14 A-MENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /4 w FACILITY/SITE NAME WHERE TANK IS INSTALLED/ 7 Z FARM TANK-YES ❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOS FY N A. OWNERS TANKIDR B. MANUFACTURED BY: CD O YEAR INSTALLEQ D. TANK CAPACITY IN GALLONS'. OC) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E3<MO VEHICLE FUEL ❑ 2 PETROLEUMB. C ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT [-] 4 OIL �RODUCT ❑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.R A C.A.S.N. III. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTE91OR LINER J ❑ 95 UNKNOWN SYSTEM .r P SINGLE WALLED ❑4 SECONDARY CONTAINMENT 'l ❑99 OTHER .�1�STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC LINING i LINING ❑5 GLASS LINING 21 ❑ UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YV NO VO7HEP D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE %UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A&72 PRESSUREA 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE W D U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL VA U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7 STEEL CLAD WEEP A U 8100%METHANOL COMPATIBLEFRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK D8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIM TED DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3, WAST K FILLED WITH N SUBST E EMAININO IN E ATERIAL? E:]YES ❑ NO GALLONS N THIS FORM HAS BEEN COMPLETED UNDER PENALTY bF PERJURY,AND TO THE BEST OF MY KNOW EDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COU INTTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N o � � 7 Llo 12-1 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAI PHONE N WITH AREA CODE t_ 23 PERMIT NUMBER PERM2A VAL DATE PERMIT EKPI TION DATE CHECK N PERMIT AMOUNT SURCHAR E AM FEE CODE gECEIPTN BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITEAPPLICATION, FORM 'A',UNLESS A RENT FORMA' HASBEENFILED DATA PROCESSING COPY __