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STATE OF CALIFORP" � WATER RESOURCES CONT BOARD FORM 'B': UNDMGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CL K ONE ITEM 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: d FARM TANK-YES NO For z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN 4SOSPECIFY to A. OWNERS TANK IDa 8. MANUFACTURED BY: C. YEAR INSTALLED UJAA D. TANK CAPACITY IN GALLONS: T1,000 A II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 A. MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESC IBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.N: ItIlA .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 124 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE [:] 7 ALUMINUM ❑B 100%METHANOL OOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL95 UNKNOWN 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 AJ&D LINING F-13 EPDXY LINING F-14 PHENOW LINING LINING ❑ 5 GLASS LINING KKUNUNED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [:]YES ❑ NO ❑99 OTHER R OR D PROTECTION E:]5 CATHODIC PROTECTION E]91TANONE ASPHALT Y 95 UNKNOWN ❑W OTHER HER REINFORCED PUSRC IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION AW 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U fi CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S VISUAL CHECK (�J'Y S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTINGT S 7 PRESSURE TESTING 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(MO/YR) 2. ESTIMATED CILIA NTITY OF3.WAS TA FILLED GALLONS WITH SUBST N fv NTNG IN I A ILUED ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF 14ERJURY,AND TO THE BEST OF MY KNOWLE GE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID Al TANK ID# d S' S" (101013 1 CURRENT LOCAL AGENCY FACILITY ID# APPR VE B NAM9 PHONE N WITH AREA CODE X16 PERMIT NUMBER P IT PPpO L D PERMIT EXPIRATION GATE CHECK# PERMIT AMOUNT -BURGH RG A T. (/(�✓ FEE CODE CEIPT# BY: y FORMB(3-7-88) THISFORM MUST BE ACCOMPANIE AFACILITY/SITE APPLICATION, FORM 'A',UNLESS ENT FORM'N HAS BEEN FUD DATA PROCESSING COPY