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STATE OF CALIFORNI WATER RESOURCES CONTROARD E G FORM `B': UNDROUND STORAGE TANK PROGRAM FpF TANK CO TANK PERMIT APPLICATION INF 54 �s MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ONE ITEM ❑ ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE � ! FACILITY/SITE NAME WHERE TANK IS INSTALLED! L�o TANK REMOVED if FARM TANK-YES NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— '' A. OWNERS TANK ID# SPECIFY B. MANUFACTURED BY: °a C. YEARlNSTALLED 11. TANK CONTENTS IF(a.i�,IS MARKED,COMPLETE ITEM C.IF(A.1D},IS MARED, (N GALLONS: A, MOTOR VEHICLE FUEL ❑ 2 PETROLEUM KED,COMPLETE ITEM D. B- C UNLEADED ❑ ❑ 2 LEADER 3 CHEMICAL PRODUCT ❑4 OIL ❑3 DIESEL ❑5 HAZARDOUS ❑ 80 EMPTY95 F!>�l PRODUCT ❑4 GASAHOL E]5 JET FUEL ❑ 6 AVIATION GAS O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF UNKNOWN ❑ ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE 1N ITEM D,BELOW) HAZARDOUS SUBSTANCE STORED&C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D CAS #. Ion A. TYPE OF ❑ 1 DOUBLE WALLED ❑ S SINGLE WALLED WITH EXTERIOR LINER SYSTEM 0"2 SINGLE WALLED ❑ 4 SE ❑ 95 UNKNOWN SECONDARY CONTAINMENT ❑99 OTHER B. TANK �1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGL4S511 4 STEEL CLAP WIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM Q ❑ 10 GALVANIZED STEEL 9 BRONZE ❑ Q 8 100%METHANOL COMPATIBLE FRP 11 95 UNKNOWN ❑ 99 OTHER 5 GLASS LINING C. INTERIOR ❑ I RUBBER LINED ❑� 2 ALKYD LINING LINING ❑ P-6 UNLINED 113 EPDXY LINING ❑4 PHENOLIC LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? W99 UNKNOW OTHER 5 CATHODIC PROTECTION D. CORROSION ❑ 1 POLYETHLENE WRAP ❑p TAR OR ASPHALT ❑YES ❑ NO PROTECTION ❑ ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC � g1 NONE 95 UNKNOWN ❑ 99 OTHER 1V. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE a 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A V 91 NONE U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 95 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4�FIERGLASS PIIPEWN A AU U919NONE ER C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAP W/FAP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A V B 100%METHANOL COMPATIBLE FRP A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION S VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS NONE P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING YI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 95 UNKNOWN P s 99 OTHER 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF SUBS AN EMAINING IN 3-WAS NK FILLED WITH GALLONS I E TERiAL?014 ❑VES [] NO THIS RM HAS BEEN COMPLETED UNDER PENALTY 0 PERJURY,AND TO THE BEST OF MY KNOWLEDGE, APPLICANT'S NAME(PRINTED&SIGNATURE) 1S TRUE AND CORRECT DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY 1D APP DYED BY QJ� PHONE N WITH AREA CODE PER TNU BER 'L' PERMIT APPROVAL DATE ER IT El(pIRATION DATE CHECK fk PERMIT AMOUNT � SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(s-zs-as} THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORAM A',UNLESS A RENT fORM'A' HAS BEEN FILED DATA PROCESSING COPY