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STATE OF CALIFOR( - A WATER RESOURCES CONTJL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ;mom TANK TANK PERMIT APPLICATION INFORMATION z COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMR Ef5 CHANGE OF INFORMATION ❑7P ANEN/jL[��Cy�B/�ED TANK ONE ITEM E]2 INTERIMPERMIT ❑4 AMENDED PERMIT [-]6 TEMPORARY TANK CLOSURE TANK REMItYELL/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3- FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-S0SPECIFY N A. OWNERS TANK IDN B. MANUFACTURED BY: -4 C.YEAR INSTALLED 1� (�- 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. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 UCT ❑4 GASAHOL ❑ 5 J EL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D .04 -� A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWYLL9n G SYSTEM ❑2 SINGLEWAUED ❑4 SECONDARY CONTAINMENT IFA4 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 UM E]B 19DAMETHANOL COMPATIBLE FRP ❑9 BRONZE E] f 0 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNEO ❑2 ALKYO LINING ❑3 EPDXY LINING ❑OIC LINING C. INTERIOR LINING ❑5 GLASSUNING ❑8 UNLINED 95 UNKNOWN ❑IS UNING MATERIALOOMPATIBLE WITH IWA METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 U 91 NONEA U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE 95 N U 99 OTHER A U 1 STEELRRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNO 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 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WEL MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P 8 1 PRESSURETESTING P S 91 NONE 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ml E= ol d CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMITAPPROVALOATE PERMIT EXPIRATION DATE HECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT N BY: Lir/ FORM B(6-29-M) THIS FORM MUST E ACCOMPANIEU'BT"A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY