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STATE r` CALIFORNIP19 'WATER RESOURCES CONTROIARD FORM `B': UNDERGROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION �w�4 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 MARK ONLY ❑ 1 PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED C/ �J FARM TANK-YES❑ NO � FACILITYISITE NAME WHERE TANK IS IN 5..--ED" ![ " 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: �1 D. TANK CAPACITY IN GALLONS: o C.YEAR INSTALLED --J! II. TANK C ENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1y,IS MARKED,COMPLETE ITEM D. B C. F--] 1 UNLEADED ❑ 2 LEADED 3 DIESEL A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ fi 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&C.A.S.# (/ V 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,IS,C,&D DOUBLE WALLED El SINGLE WALLED WITH EXTERIOR LINER UNKNOWN A.TYPE OF [:] ❑99 OTHER SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIEIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE FS—] 7 ALU El 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 19 GALVANIZEDSTEEL 5 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH LINING C. INTERIOR ❑ 5 GLASS ❑ 6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MFTHANOL7 ❑YES ❑ NO ❑ 99 OTHER D.CORROSION 1 POLYEfHLENE WRAP 2 TAR OR ASPHALT ❑3 VI RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODYC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(r'UjjPHESSURz 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 A 5 UNKNOWN A U 99 OTHER A U 1 STEELLRON A U 2 STARLESS 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 B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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, 4 S VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADCSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P, PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER - vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3. WAS TANK FILLEDW�ITH� C!!t��SUBSTANCE STIMATED QUANTITY OF INERT MATERIAL? 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&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY 1D# TANK ID# COUNTY# JURISDICTION# AGENCY# C APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL GENCY FACILITY I # PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAtE FEE CODE REGEiPT k BY: CHECK# PERMIT AMOUNT SURCHARGE AMT. HAS BEEN FILED FORM B(6-z9-aa) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' DATA PROCESSING.COPY