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STATE OF CALIFORNIA WATER RESOURCES CONTRC 90ARD FORM `B': UNDMGROUND STORAGE TANK PRO'nRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE �REMOVED O4 w ^� FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: © � 1 W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFYCD A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A [9'1MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 70k2 C. ❑ 1 UNLEADED DED ❑3 DIESEL ❑3 CHEMICAL PRODUCT F-1 4 OIL DUCT ❑4 GA AHO ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWNTE ❑ 7 METHANOL [—] 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUBSTANCE STORED&G.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ ❑99 OTHER 9 BRONZE ❑10 GALVANIZED STEEL �i'95"tlRRPDWTI ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING /—❑3 EPDXY LINING ❑4 PHENOLIC UNING C. LINING INTERIOR ❑5 GLASS LINING F-16 UNLINED KNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 1W%METIIANOL? ❑YES ❑ NO -'J:; TNER I D ORROSIOON ❑ 5 C4TYETHUE EWRAP10N ❑91TNOOE HALT ❑ 3 VINYL WRN ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ ❑ .�- ❑ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 A U UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A(U 91 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUNKNOWN 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 8 PRECISION TESTING P & 7 PRESSURETESTING P B 91 NONE P 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS T INK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Em Idold a 101010111 CURRENT LOCAL AGENCY FACILITY ID# M APPROVED BY NAME - PHONE*WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: 1 FORM a Is-z9-esl THIS FORM MUST BE ACCOMPANIED tY A FACILITY/SITE APPLICATION, FORM `A',UNLESL JRRENT FORMA' HAS BEEN FILED V DATA PROCESSING COPY