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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM YL TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :d MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITE ❑ 2 INTERIM PERMIT ❑4 AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IG A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED ) 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. wW A F-1 3 CHEMICAL PIR DUCTL F-1 4 OIL ROLEUM B. i PRODUCT O ❑4 GNASAHOLD ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 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.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUM) ❑B 10D%METRANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENO CLINING LINING ❑5 GLASS LINING ❑6 UNLINED /7 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHA L? • ❑YES ❑ 99 OTHER D. CORROSION ❑ 1 PDLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VI AP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 99 OTHER 8. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5ALUMINUM A Jl ACONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/`6 SA 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1�U'F P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE If 8 95 UNKNOWN P S 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 IN GALLONS INERT MATERIAL? [:]YES 0 N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY �COOU�NTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I L� C9 U 3 U O I G CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NA E / PHONE#WITH AREA CODE v cHtiA(�/ PERMIT NUMBER PERMIT APP ROV 0 T PERMIT E PIRA ON DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. �OY FEE CODE RECEIPT N BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED $� DATA PROCESSING COPY