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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .". [FACILITY/SITLEYNAME ARK ON ❑ ❑3 RENEWALPERMI7 CHANGE OF INFORMATION jFARM PERMANENTLY CLOSED TANK 0 1 NEW PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED/�,2„ WHERE TANK IS INSTALLED: ANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I A. OWNERS TANK ID R &G — B. MANUFACTURED BY: 4 000 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 7 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM FKI C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ODUCT ❑d GASAHOL ❑5 JET FUEL ❑fi AVIATION GAS 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �NGLE WALLS) ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM E]8100%METHANOL COMPATIBLE FRP MATERIAL F-19 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNEDUNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2 TAR OR ASPHALT ❑3 VI l-WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE KNOWN ❑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 UNED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A �U�6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1 DIM 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. L, f P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �r�/J1 P 5 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(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES F] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# (i D / =01013 CURREN CAL AGENCY FACILITY ID 0 APPROVED BYN ME PHONE#WITH AREA CODE is PERMIT NUMBERJ PERMIT APPNOVAL DATE RMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANY. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPA D�SF A FACILITY/SITE APPLICATION, FORM 'A',UNLESSW RENT FORMA HAS BEEN FILED