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STATE OF CALIFORN01 WATER RESOURCES CONTP BOARD FORM `B': UNDVhGROUND STORAGE ILNFORMAT TANK. A OMPLETE TANK TANK PERMIT APPLICATION CA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 0 3 FARM TANK-YES ❑ NO IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: - N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 44 I1. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL [—] 2 P ROLEUM B. C. E] 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 P UCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN UKWASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF r �� O r / C.A.S.#: ©� HAZARDOUS SUBSTANCE STORED&C.A.S.# �l III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN Z SIN SYSTEM g1GLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 111 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑ 4 PHE LINING LINING ❑ C. INTERIOR 5 GLASS LINING F-16 UNUNED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WRH 100%METHANGL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONENKNOWN ❑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 <ujrRAVlTY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 4 6 PRECISION TESTING P S 7 PRESSURE TESTING It P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOLAR) 2.ESTIMATED QUANTITY OF 1 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [-] NO GALLONS 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# TANK ID# 17-/ O CURRENT LO AGENCY FACILITY ID APPROVED BY NAME Dµ�j PHONE WITH AREA CODE PERMIT NUMBER j PERMIT APPROVAL DATE PERMIT XPIRATIOND�ATTEE. CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY: FORM B(6-29-BB) THIS FORM MUST BE ACCO MPANIL,_oA FACILITY/SITE APPLICATION, FORM'A',UNLESS A'L'ORRENT FORMA' HAS BEEN FILED / DATA PROCESSING COPY