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(ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM r TANKTANK PERMIT APPLICATION INFORMATION z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OFINFORMA710N ❑ 7 PERMANENTLY CL SEDm ONE ITEM ❑ 2INTERIM PERMIT ❑4 AMENDED PERMIT 56 TEMPORARY TANK CLOSURE ANK REMOVED144 12111 O FARM TANK-YES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: O) 0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# I B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ig1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL p� ❑4 GASAHOL ❑ 5 JET FUEL [:]6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL hJ-�5 PRODUCT ❑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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,S D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER Xj5 UNKNOWN SYSTEM ❑ 2 SINGLEWALLFD ❑4 SECONDARY CONTAINMENT I ❑ 99 OTHER ❑ 1 STEB-PROM F-12 STAINLESS STEEL Q3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ ALUMINUM ❑ B 100%MEFHANOLCOMPATSLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑ EPDXY LINING. ❑4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS UNING ❑6 UNUNED E95 UNKNOWN LINING ❑ IS LINING MATERIAL OOMPATTBLEWITH IDD%METHANB[TJ YES ❑NO ❑99 OTHER 1 D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑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 ASUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 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 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A IJ4 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6195 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 1 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED OUANTITY OF NK FILLED WITH 3.WAS TA SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID# TANK IO# oo ?-1 1 CURRENT LOCAL AGENCY FACILITY IDN APPROVE BY NAME PHONE N WITH AREA CODE �,3 o G PFA NUMBER PERMIT APPROVAL DATE PE MiT IMT DATE CHECK N PERMIT AMOUNT 'RCHARGE AMT. FEE CODE R' RIPT N BY: 11Y� FORM B(629-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED „kk DATA PROCESSING COPY