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STATE OF CALIFORNIA FORM `B': WATER RESOURCES CONTR OARD UNDE GROUND STORAGE TANK PROAM TANK TANK PERMIT APPLICATION INFORMATIONQp COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 2 INTERIM PERMIT 7 PERMANENTLY CLOSED TANK 1 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� I ❑B TANK REMOVED /191 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWNL e O FARM TANK-YES E] NO CA) A. OWNERS TANK ID q SO SPECIFY Cfl C. YEAR INSTALLED B. MANUFACTURED BY: a) 11. TANK COEE:��—� NTENTS ( 1 D. TANK CAPACITY IN GALLONS: IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A. Ej 1 MOTOR VEHICLE FUEL []2 PETROLEUM 3 CHEMICAL PRODUCT E] 4 OIL 6. C. ❑ 1 UNLEADED E]2 LEADED 1 PRODUCT 4 GASAHOL ❑3 DIESEL 5 HAZARDOUS 080 EMPTY � 95 UNKNOWN 2 WASTE ❑ ❑ 5 JET FUEL 0 6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑ 7 METHANOL Ej 9g OTHER(DESCRIBE IN ITEM D, HAZARDOUS SUBSTANCE STORED&C.A.S.q BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,CIA D C.A.S.q: A. TYPE OF ❑ 1 DOUBLE WALLED 03 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ED 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑95 UNKNOWN 99 OTHER B.TANK ❑ I STEEL/IRON �2 STAINLESS STEEL MATERIAL ❑5 CONCRETE ❑3 FIBERGLASS 4 STEEL CUD WAHBERGLASS REINFORCED PLASTIC 6 POLYVINYL CHLORIDE 07ALUMINUM ED8 I OA METHANOL COMPATIBLE FRP 9 BRONZE El 10 GALVANIZED STEEL El 95 UNKNOWN 99 OTHER C. INTERIOR ❑ IgUBBER LINED 02 ALKYD LINING LINING ❑ 5 GLASS LINING 0 ❑3 EPDXY LINING 4 PHENOLIC LINING 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH IDO%METHANOL? ❑95 UNKNOWN YEB 0 NO E] 99 OTHER D. CORROSION El 1 POLYETHLENE WRAP 02 TAR OR ASPHALT PROTECTION E]5 CATHODIC PROTECTION97 NON ❑3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC E � g5 UNKNOWN IV. PIPING INFORMATION 99 OTHER CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U 5 ALUMINUM A U 3 POLYVINYL CHLORIDE(PVU 4 FIBERGLASS P C) A IPE A A U 6 CONCRETE A U 7 STEEL CLAD W/FRP U 91 NONE A U A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 99 OTHER U 8100%METHANOL COMPATIBLE FRP V. 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 P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 99 orHER- 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3,WAS TANK FILLED WITH 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION q AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY IDN / /'1 �O APPROVED BY NAME l•� PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE gECE1PTN BY: FORMIB(6-29.88) THIS FORM MUST BE ACCOMPANIE f A FACILITY/SITE APPLICATION, FORM 'A', BEEN FILED UNLESS A RENT FORMA' HAS DATA PROCESSING COPY