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STATE OF CALIFORNI4& WATER RESOURCES CONTRONWARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM m" TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O I N ERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ❑ DZ ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY l B. MANUFACTURED BY: L�r�'�� A. OWNERS TANK ID# C. YEAR INSTALLED (�Ci/I, - D. TANK CAPACITY IN GALLONS: �e II. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NaT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED 2 LEADED DIESEL A. 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 PRODUG7 ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT F-1 4 OIL ❑ ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF „1 / C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 2:V III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1000BLEWALLED ❑3 SINGLE WALLEDWRH EXTERIOR UNER 5UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC - B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 AL M ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERLINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PH CLINING C. INTERIOR 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN LINING E] 15 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ES99OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL P ❑4 RBERGLASSREINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE NKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 96 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 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A jru5 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAB TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO R) 2. ESTIMATED QUANTITY Of INERT MATERIAL? YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FNUMBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# APPROVED BY NAME WITH AREA CODE EIbc1'FACILIT'!ID p � fTll/,qV/ PERMIT APPROVAL DA PERMIT XPIRATION CHECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIEAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A FORM 'A'FORA' HASBEENFILED - _ DATA PROCESSING COPY