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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. Z 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ( W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY F+ A. OWNERS TANK ID# B, MANUFACTURED BY: C YEAR INSTALLED /moi /`/ 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. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL RODUCT ❑4 GASAHOL ❑ 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&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM li-e"IBNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EV STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PIABRC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81M%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UNING 8 UNLINED ❑ 95 UNKNOWN 4/ ❑ IS LINING MATERIAL COMPATIBLE WITH UK%METHANOL? ❑YES ❑ NO �OTHER V n k D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A .0 99 OTHER B.CONStRUCTION A U 1 SINGLE WALLED A U 2 UBLE WALLED U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U W OTHER A STEEL/IRON A U, STAN SS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONC E A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U1 JB U "OWN 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 P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �J'WI P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI GALLONS MATED DATELAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑Y ❑NO THS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENTT B AL AGENCY F CILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE o PERMITNUNBER PERMR PPROVAL DA PERMITEXPI ATIOND TE 0 0 i �� /a CHECK# PERMIT AMOUNT SURCHARGE AfAT. ACEIPT# BY: \ FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIEL ,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CGRAENT FORMA' HAS BEEN FILED ) DATA PROCESSING COPY