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STATE OF CALIFORWA WATER RESOURCES CONTL BOARD s« , FORM `B': UN tRGROUND STORAGE TANK PGRAM �=-_=;AIA : TANKj TANK PERMIT APPLICATION INFORMATION MPLETE A SEPARATE FORM WITH THE FOLLOWING 1 iLJ INFORMATION FOR EACH TANK. [FACILITY/SITE ;RKNLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY K EM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE NAME WHERE TANK IS INSTALLED: ) S' ._ o?j) FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY S��,v A. OWNERS TANK I�4 '( B.�TANK CTURED BY: C. YEAR INSTALLE / D. PACITY IN GALLONS: II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. k ffl7MOTOR VEHICLE FUEL ❑ 2 PETROLEUM [q4l�l_PRODUCT . / C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ q OIL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ STE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.q: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF E] I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ gg OTHER B ElI STEEL/IRON El2 STAINLESS STEEL ❑3 FIBERGLAS- ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE E]7 A NU�UM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL EZ�i UNKNOWN ❑99 OTHER C. INTERIOR ElNING 1 RUBBER LINED ❑ 2 ALKYD LI3 EPDXY LINING El PHENOLI ING ❑ LINING ❑ 5 GLASS LINING ❑6 UNLINED tHE WN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO R9 D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑99 OTHER 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 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A UU STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FWR'GLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM g CONCRETE A U 7 STEEL CLAD W/FRP ` A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN A U 99 OTHER (W-11 V. L DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER ` V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES E] 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# jLIYD# -� ` TANK ID# Ne- CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME - 0= ( PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE -07 RECEIPT N BY: r FORM B(6-29-88) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES:A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY