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STATE OF CALIFORNIks WATER RESOURCESCONTRC IOARD '� ,"'T Z FORM B': UNDEWGROUND STORAGE TANK PRO!5° AM m TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK MARK ONLY ❑rI PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM •l�L-/T'o�INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED a FARMTANK-YES❑ NO ❑ a FACILITY/SITE NAME WHERE TANK IS INSTALLED: (D I 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N B. MANUFACTURED BY: It, A. OWNERS TANK ID# C.YEAR INSTALLED D.TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED TRIN 3 DIESEL❑ 3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE7 METHANOL ❑99 OTHER(DESITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF d C.A.S.M HAZARDOUS SUBSTANCE STORED&C.A.S.# rJ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WAUED ❑4 SECONDARY CONTAINMENT ❑W OTHER BTEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑2 ALODUNING ❑3 EPDXYUNING ❑�4 PHENOLIC LINING C. INTERIOR F-15 GLASS LINING ❑6 UNLINED U "UNKNOWN LINING ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 IWLWRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE VUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Aq9 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAO W/FRP A U B 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AID 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. ,1 P S 1VISUALCHECK 08 2 INVENTORY RECONCILIATION P 8 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS -I P 6 PRECISION TES TING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH a GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO (J THIS 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# TANKID# [ = = 10d 1 / jai 1 cl oC) � CURRENT LOC AGENCY FACILITY ID# APPROVED BY NAM PHONE#WITH AREA CODE �� . PERMIT NUMBER PERMIT PPROV DA PERMIT IDWRATION ER gr, CNECK# PERMITAMOUNT Ill ARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-80) THIS FORM MUST BE ACCOMPANIEI)!IT'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AERT FORMA' HAS BEEN FILED I?. ,INCA COPY