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STATE OF CALIFORP� N WATER RESOURCES CONT BOARD FORM 'B': UNDERGROUND STORAGE TANK PRI GRAM TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1NEW PERMIT ❑3RENEWAL PERMITCHANGEOFINFORMATION ❑ 7PERMANENTLY CL H I� ONE ITEM F-12 INTERIM PERMIT E-1 PERMIT 6 TE4 AMENDED MPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: b IFApM TANK-YES❑ NO CyrN I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W W A. OWNERS TANK ID# B. MANUFACTURED BY N ' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /pj,900 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JEf FUEL ❑ 6 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 ,�11 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#' /.1 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D 1 UBLEWALLED F--] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A TYPE OF I::] SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED El2 A LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 0 N�� /I��// F-1ISLININ MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES El NO 99 OTHER` ✓" D.CORROSION ❑ OLYETHLENEWRAP [—]2 TAR OR ASPHALT F73 VINYL WRAP F--] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAB ROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U' 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM Afi CONCRETE A U ] STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 4 P S- 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED)MO/VR) 2. ESTIMATED ANTITV OF 3. WAST NK FILLED WITH L1 SUBSTAN MAINING IN E TERIAL? YES ❑ NO ✓�L GALLONS THIS FO M HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOW EDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENTILCAl AGENCYACIU IDM APPROV Y NAM PHONE N WITH AREA CODE PERMIT NUMBER LDJ` PERMIT APPROVAL DATE /PIBIMIT EXORATiclIN DATE CHECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT R BY: I FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEL !A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY