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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM Fk TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: r_qt% FARM TANK-YES❑ NO - L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C7 A. OWNERS TANK ID# !� B. MANUFACTURED BY. h C. YEAR INSTALLEDlclgqD. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 MICAL PRODUCT ❑ 4 OIL ❑ 1 PROD CT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL ff?r9_OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF U+04 M 1433 3l HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS #. +SI Sa�� 13) xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER F] I STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 100% OL COMPATI8LE FRP ❑ 9 BRONZE E:] 10 GALVANIZED STEEL ❑ 95 UNKNOWN OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 AL LINING El 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING EglrUNLINED ❑ 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TMi4ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION I NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U dF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 099 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/ERR A U 6 100%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 Cl P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U5€0(MO/YR) 2. ESTIMATED QUANTITY pF GALLONS 3. WAS TANK FILLED WITH LSUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO �JJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED$.SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TAANK ID# CURRENT LOCA' GEY FACILITY #� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY; l! FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIOW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A w RENT FORM`A" HAS BEEN FILED DATA PROCESSING COPY