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STATE OF CALIFORNIA • WATER RESOURCES CONTROL B4pD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIV INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 PER TEMPORARY TANK CLOSURE KREMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: !� a FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDR B. MANUFACTURED BY: ()'( C. YEAR INSTALLED k AllD. 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 PETROLEUM R. C. E] 1 UNLEADED E] 2 LEADED E]3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL i PRODUCT ❑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&CA.S.R 57Cl>DPfP-3> sot vENT C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A TYPE OF ❑I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNEP 95 UNKNOWN SYSTEM ❑2 SINGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810996 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL �ORKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 ALKYO LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED E3-%-MNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 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 A CU 5 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 5ALUMINUM A6CONCRETE A U 7STEEL CLAD W/FRP A U 01 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 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 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT ST USEj( GALLONS YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH 1 ZJ SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES NO t L THIS FOR HAS BEEN C MPLETED 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 R JURISDICTION M AGENCY R FACILITY I R TANK ID R aso ,CU RREN OCAL AGENCY FACILITY IDM APPROVED BY NIUE PHONE N WITH AREA CODE ti P PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT I SURCHARGEAMT. FEECODE RECEIPT BY: lb Aft FORM B(629-38) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A u RENT FORMA' HAS BEEN FILED -/}- DATA PROCESSING COPY