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STATE OF CALIFORNIft WATER RESOURCESCONTROARD ?s FORM `B': UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �.TLJ FARM TANK-YES❑ NO .-L FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1© I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFYE] " A. OWNERS TANK IDX B. MANUFACTURED BY: ,-1 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C(WENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,CO ETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL , ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GABAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLEWAL ED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM GLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER TEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ i RUBBER UNED ❑2 ALKYD,IJNING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNING C.INTERIOR ❑5 GLASS UNING UNED ❑95 UNKNOWN LINING ❑ IS UNING MATERIALCOMPATIBLEWRH 100%METIiANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLENEWRAP ❑2 T PHALT F-13 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION I NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 96 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FISERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AI: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 $ 1 VISUAL CHECK �/P/S 2 INVENTORY flECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S - PRECISION TESTINGVP S 7 PRESSURE TESTING P 8 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE &WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO GALLONS THIS FORM HAS BLtN 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# FTANK # APPROVED BV NA pNONEX CODE CURRENT LOPAL AGENCY FACILITY I # i Y PERMIT NUMBER PERMIT APPROVAL DA PER EXPIRATION ATE CNECKX PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY