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J I H t vF CALIFORNIA _ WATER RESOURCES CONTROL ' ARD FORM B : UNDERGROUND STORAGE TANK PROGRAM °: TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK, �_m- MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT f•` ��' Z ONE ITEM ❑2 INTERIM PERMIT 4 5 CHANGE OF INFORMATIONto ❑ AMENDED PERMIT PERMANENTLY CLOSED TANK ❑6 TEMPORARY 7 TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑8 TANK REMOVED C I. TANKDESCRIPTION COMPLETE ALL I7EM3-IF UNKNOWN- N � FARM TANK-YES NO ❑ I„a A. OWNERS TANK ID q SO SPECIFY 00 o / B. MANUFACTURED BY: 4 C. YEAR INSTALLED N I. TANK N GALL NS 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1) CAPACITY ,S NOT MA MARKED,COMPLETE ITEM D. A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑4 OIL B Q ❑4 UNLEADED 2 LEADED 3 DIESEL ❑ ❑80 EMPTY 95 UNKNOWN ❑ 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑ ❑2 WASTE ❑ 7 METHANOL El OTHER(DESCRIBE IN ITEM D,BELOW) HAZARDOUS SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D C.A.S.#: A.TYPE OF ❑ 1 DOUBLE WALIID ❑3 SINGLE WALLED WITH D(IEHIOR LINER SYSTEM 95 UNKNOWN ❑2 SINGLE WALLED ❑4 SECONDARYGONTAINMENT ❑99 OTHER B.TANK ❑ 1 STEEUIRON ❑2 STAINLESSfiTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXYUNING ❑4 PHENOLIC LINING LINING F-15 GLASS UNING ❑6 UNUNED ❑95 UNKNOWN ❑ IS UNINGMATERIAL COMPATIBLEWITH 100%MEIHANOL? YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 WNYLWRAP 4 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 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 5ALUMINUM A U 6CONCRETE A U 7STEELGLADW/FRP A U 81 OD%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 f 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P f 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOLAR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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. APPLICANTS NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COOUNTY�# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I I I ell i 5vI 010111 CURRENT LOCAL AGENCY FACIUTV ID# APPROVED BY NAME PHONE t WITH AREA CODE PERMIT NUMBER %✓l PERMIT APPROVAL DATE PERMIT EXPIRATIdk DATE CHECK# PER MIT AMOUNT SURCHARGE AMT. FEECODE I RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANI A FACKJTY/WRE APPLICATION, FORM 'A',UNLESS A RELAY FORMA' HAS BEEN FILED 0v • DATA PROCESSING COPY