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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM , TANK TANK PERMIT APPLICATION INFORMATION C COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWALPFAMIT Fvf5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED S W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ger N N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEARINSTALLED 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 PETROLEUM B. O. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑1 GASAHOLET 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 OFgg� HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK it,B,C,8 D A.TYPE OF ❑ 1 LE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER AALL�� ❑ 1 RUBBER LINED ❑2 LINING F-13 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR / LINING ❑5 GLASS LINING I�-I6 NING UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%MEMMOL? RYES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALTNYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASRC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTN IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVIN A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8, CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A'fi 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS 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 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 15 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. / P 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 1 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I P S 6 PRECISION TESTING P 6 ] PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATEDDAT ST USED IMO/YR) 2. ESTIMA EDOUANTITYOF 3.WA ANK FILLED WITH GALLONS BGS SU EMAINING IN IN AIATERIAL? ❑YES ❑ NO ///��V THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURp{NT NLAPPROVEDID# APPROVED BY NAM . PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA ')CESSING COPY '