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h 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. o ;* MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED ID FACILITY/SITE NAME WHERE TANK IS INSTALLED: - 9 FARM TANK-YES❑ NO ❑❑ F� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID Al '�_ r B. MANUFACTURED BY: J C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I--� A. ❑ 1 MOTO VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 MICAL PRODUCT ❑ 4 OIL ❑ 1 P OCT ❑ 4 GASAHOL ❑ €L ❑ 6 AVIATION OAS HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 14-313`l HAZARDOUS SUBSTANCE STORED&C.A.S.# C- G II n 7(rc(-'g0cl C.A.S.#:50 ttC,V'1 1"31 47,32- XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 44 711 fr -)(og704S 12 20 3 A.TYPE OF ❑ I D) E WALLED ❑ 3 SINGLE WALLED WITH ETERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE F-] 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN THER ❑ 1 RUBBER LINED ❑ 2 C. INTERIOR A O LINING ❑ 3 EPOA1 LINING E] 4 PHENOLIC LINING LIMING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ASPHALT ❑' 3 VINYL WRAP ❑ 4 FI8ERGLASSREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NON€ 95 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 U 2 PRESSURE A U 3 GRAVITY A 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLEWALLED A U 3 tINEDTRENCH 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/FRP 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 CIRCLED. 1t� P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TEST{NG P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED,{ O/YR 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ❑ NO THIS FORM NAS RFFk COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT APPLICANT'S NAME(PRINTED&&GNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 121� 1 1 11 Ll I I Ll (-'I IT, (�I Fr I-r CURRENT LO ALA N/C/Y�FIA I/CITY 10# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM a(3-7-8a) THIS FORM MUST BE ACCOMPANIES A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY