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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. _ry MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT E15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK (C ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 157 1 -4 (,`,,t FARM TANK-YES❑ NO I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O7 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED C I D. TANK CAPACITY IN GALLONS: I, II. TANK FT CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. j A. ff1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. F] 1 UNLEADED W2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL 01 PRODUCT ❑4 GASAHOL ❑5 JET FUEL, ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Li"`STEBJIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINE ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING 5k,UNUNE ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PDLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A w SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION �,,A w1 SINGLE WALLED A U 2 DOUSLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8109%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. f' P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING 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.ESTIMATE DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N PHONE#WITH AREA CODE 13 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FCRMB(6-29aB) THIS FORM MUST BE ACCOMPANIEL ePAFACILITY/SITE APPLICATION, FORM 'A',UNLESSA FORMA' NASBEENFLEO _. "OPY