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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. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED`TANK ONE ITEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT ❑ ❑6 TEMPORARY TANK CLOSURE ❑STANK REMOVED ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARAITANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED, OMPLETE ITEM C.IF(A 1),IS NOT MARKED,COMPLETE ITEM D. Q A, ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ ED 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.#: III. TANK CONSTRUCTION MARK ONE ITEM 4LY IN Box A,B,C.A D A.TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE W DWITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SEDONOA MAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS ST L ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGIASS REINFORCED PLASTIC B �TANK ❑5 CONCRETE ❑6 POLYWNYL CHL IDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 19 GALVANIZED L ❑95 UNKNOWN ❑99 OTHER �I 1 C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASSUNING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYEMLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 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 S GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLEA A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2STAINLESS STEE A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADO WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED A PLACE 1.ESTIMATED DATE LAST 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O � / 100101 CURRENT L CAL AGENCY FACILITY ID# APPROVE BY NA E PHONE#WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FA., ITY/SITE APPLICATION, FORM 'A',, CURREF 3RM'A' HAS BEEN FILED DATA PROCESSING COPY '�