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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION CO PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: n F. FARM TANK - YES ❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK IDM B. MANUFACTURED BY: moo -Al C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: Itwo ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS II. TANK BONTENTS IF OLI1. IS MARKED. COMPLETE ITEM C. IF MAI. IS NOT MARKED. COMPLETE ITEM D.i A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ 1 BLE WALLED C. ❑ 1 UNLEADED 2 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 (DESCRIB I ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S. R C.A.S. W 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D IV. L A. TYPE OF ❑ 1 BLE WALLED F__]3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN % SYSTEM NGLEWALLE9 E]4 SECONDARY CONTAINMENT ❑99 OTHER 1 B. TANK ❑ 1 STEEL/IRON El STAINLESS STEEL ❑ 3 A USS F-14 STEEL CLADWIFIBERGUSS REINFORCED PLASTIC,?: f" A ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ LUMIN UM ❑ 8100%METHANOL COMPATIBLE FHP MATERIAL F]9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER U 2 STAINLESSSTEEL )/C CONCRETE UNKNOWN ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 ENOUC LINING C. INTERIOR LINING F-15 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑ YYESS � NO ❑ 99 OTHER D. CORROSION F—]I POLYETHLENE WRAP ❑ 2TAR OR ASPHALT n;yvINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER YIYINU IN FUHMAI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3. WAS TANK FILLED WITH A. SYSTEM TYPE INERT MATERIAL? ❑ YES E] NO U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A�95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 95 UNKNOWN A U 99 OTHER C. MATERIAL A A A U 1 STEEL/IRON A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U 2 STAINLESSSTEEL )/C CONCRETE UNKNOWN A A A U 3 POLYVINYL CHLORIDE (PVC) A U U 7 STEELCLAD W/FRP A U U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 8 1 OD% METHANOL COMPATIBLE FRP L K DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3VAOOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER ,flu VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES E] NO DALLONB THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS T HUL ANu cc APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY IRECT. COUNTY M JURISDICTION R AGENCY k FACILITY ID B TANK ID k o / 6 v CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE M WITH AREA CODE IPERMIT NUMBER PERMIT APBROVAL DATE PERMIT EXPIRATION DATE I CHECK 4 PERMITAMOUNT PERMIT AMOUNT SURCHARGE AMT. FEE CODE CODE "CEIPT b BY: rno.. a ....... n, TNIA FDAM MIIST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM `A'. UNLESS A DAA PROCESSING COPY FORMA' HAS BEEN FILED Z 1 O 1