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. STATE OPCALIFORN6.. WATER RESOURCES CONTR��,80ARD FORM,'B' I UNDERGROUND STORAGE TANK PROGRAM TANK., TANK PERMIT APPLICATION INFORMATION ' .n. COMPLETE A SEPARATE FORM WITH THE FOLLOWING i RMATION FOR EACH TANK. Z 10 MARK ONLY .>• ❑ 1 NEW PERMIT. ❑0 RENEWAL PERMIT 02<CHANGE OF INFORMATION 7 PERUANENTLY K ONE ITEM (_(,. ,';❑ 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑S TANK REMOVED f'. FACILITY/SITE NAME WHERE TANK 18 INSTALLED: G RM TANK•YES NO FV O 1. TANKOESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN—SO SPECIFY (0 A OWNERS TANK ION ' qK B. MANUFACTURED BY: G C.YEAR INSTALLED p D. TANK CAPACITY IN GALLONS:- 11. ALLONS:11. TANK CONTENTS IF(A1).18 MARKED,COMPLETE ITEM C.IF(A.1).IS ARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PET MB. C. ❑ 1 UNLEADED ❑2 LEADED ❑S DIESEL ❑3 CHEMICAL PRODUCT OIL 1 PRODUCT ❑I GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS - ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0•BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF ^ HAZARDOUS SUBSTANCE STORED 8 CAS.1. NEW- !V I L CAS.N: OF III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA.B.C.&D A.TYPE OF 1 ❑ 1.DOW WALLED ❑7 SINGLE WALLEDxttHDOERORLINER ❑95 UNKNOWN SYSTEM :.' ❑2 SINGLEWAUEO I SECONOAWCONTARMENT ❑99 OTHER ❑ I STEEURRON 2 STAINLESSSTEEL ❑S FIBERGLASS ❑1 STEL CUD W/fIBERGASS REWFORCED PLASTIC 8.TANK. MATEflU1L ❑5.WINCIETE - ❑F POLYVIIMOEARDE r77 AWWNUM ❑6100%METHANOL COMPATIBLE FRP - ,;. ?:; ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 URXN0A ❑99 OTHER C.INTERIOR' I RIBBEAUNED .. ❑2 AM LINING ❑ 2 EPOZYUNNG ❑K PHENOUCLIMNG LINING, ;`.. ❑ S GLASS UN00 ❑1 UNIMED ❑95 UNKNOWN '' . '❑BiUWNG WTERAI.COWATIBLEW1MIW%U RWa? ❑YES ❑NO ❑ 99 OTHER D.CORROSION . ❑ I.PO.YEDLMWRM ❑2 TAR OR ASPHALT ❑2 VIWLWRAP ❑S RBERGIASSREINFORCED PLASTIC PROTECTION ❑5 cAmo CPROTECTDN ❑91 NONE ❑ 95 Uh0NOWN ❑99 DIM IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U B GRAVITY A U 91 NONE A U 25 UNKNOWN—A U 99 OTHER S.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 57EEUIRON A U 2 STAINLESSSTEEL A U 7 POLYVINYLCHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A V 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P E I YISUALCHECK P 9 2 INVENTORY RECONCILIATION P S 0 VADOSE WELLS P t I ELECTRONIC MONITOR P 1 5 GROUND WATER MONITORING WELLS P I 1 PRECISION TESTING P 1 7 PRESSURE TESTING P / 91 NONE P 1 95 UNKNOWN P 1 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON( INERT MATERIAL? YES [3NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT;5 NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# ' '.JURISDICTION P AGENCY 1 FACILITY IDI TANK ID E CURRENT LOCAL ADENY F70DILITY 10 1 APPROVED BY NAME PHONE I WITH AREA CODE i10• PERMITNUMBEA PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMITAMOUNT BUBCHARGEAMT. FEE CODE ECEIPTS _• •._ FORMB(6.29-aa) THIS FORM MUST BEACCOMPANIED BYAFACIUTY/SITFAPP(.ICATION. I:naU 'A' ,........,_..__