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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM • TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - _- z MARK ONLY F-] 1 NEWPERMIT F-13 RENEWALPERMIT ❑5 CHANGE OF INFORMATION E] 7 PERMANENTLY Cl-qSED TAN10 1 O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED/a FACILITY/SITE NAME WHERE TANK IS INSTALLED: Fo{ FARM TANK-YES❑ NO Er IIV nJ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDp B. MANUFACTURED BY: C. YEAR INSTALLED �„„ D. TANK CAPACITY IN GALLONS'. S 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E�fl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED [:]2 LEADED DIESEL • F-] 3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑M EMPTY [:]95 UNKNOWN ❑2 WASTE ❑7 MIEHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.p C.A.S.p: A 111. TANK CONSTRUCTION MARK ONE ITEMONLY IN BOXA,B,C,BD A. TYPE OF ❑ I UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2112 SINGLE WALLED ❑4 SEC ONDAR(CONTAINMENT ❑99 OTHER STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD WIFIBERGLAS4 REINFORCED PLASTIC B. TANK I MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 10D%MEMANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ©8 UNUNED ❑95 UNKNOWN [:] ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? -]YES ❑ NO OTHER D. CORROSION ❑ I POLYETILENEWRAP [212'TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A(Uj I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A&1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELASON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A I 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U S 10M MUHANOL 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. NP S P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Y� P 8 6 PRECISION TESTING P 5 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIM TED QUANTITY OF 3.WAS ANK FILLED WITH 5 B CE REMAINING IN I ATERIAL? E]YES ❑ NO GALLONS THIS ORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION p AGENCY p FACILITY ID p TANK ID p In a o CURRENT LOCAL AGENCY FACILITY ID n APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERmtr ExpiKAnON DATE CHECK p PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: U v FORM B(6-29-89) THIS FORM MUST BE ACCOMPANIEbmWA F ISITE APPLICATION, FORM 'A',UNLESS A CUARENT'FORM'A' HAS BEEN FILED DATA PROCESSING COI' /