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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 5 CHANGE OF INFORMATION ❑ 7 PE ANENTLY CLOSED TANK 1 ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMR ❑ 6 TEMPORARY TANK CLOSURE ANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTT A. OWNERS TANK ID# B. MANUFACTURED BY: µ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. V 11. TANKCONTENTS 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. C. ❑ 1 UNLEADED ❑ 2 LEADED El DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL E-.�PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DE IBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.B.# CA.S.#: III. TANK CONSTRUCTION MARK ONE I ONLY IN BOX A.B,C,&D A.TYPE OF ❑1 BIEWAU-ED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 21�1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 810M METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 2 LINING ❑3�OXYUNING ❑4 PHENOLIC LINING 1 RUBBERUNED ❑ C.INTERIOR 5 GIABS LINING 6 UNUNED ❑ KNGWN LINING ❑ ❑ IS LINING MATERIALCOMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER ""� ' D.CORROSION ❑ 1 POLYETKENEWAAP ❑ 2 ORASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION Z91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEMTYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER NSTRU B.CONSTRUCTION SINGLE SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 9/ NONE C.MATERIAL A U Ia14LUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 81 DD%METHANOL COMPATIBLE FRP A 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. P 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING _ P NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIM TED DATE UST USED(MO/YR) 2. ESTI TED QUANTITYINOF 3. AS TANK FILLED WITH S B REMAING IN MATERIAL? ❑YES E] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTf OF PERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID R TANK ID 8 O l1 HREDc CURRENT LOCAL AGENCY FACILITY IO x APP V D BY PHONE#WITH AREA CODE �� Gla AP?P1% PERMIT NUMBER PERMIT APPROVAL DAT PER IT EXPIRATION DATE CHECK# vERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FOPM B(e-29 88) THIS FORM MUST BE ACCOMPANIEVO A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA HAS BEEN FILED DATA PROCESSING COPY