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WATER RESOURCES CONT ARD ; - rte. STATE OF CALIFORIft4 , xo UNDERGROUND STORAGE TANK PROGRAM FORM 'B': TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACHQN PERMANENTLY CLOSED TANK ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 8 TANK REMOVED ❑ 1 NEW PERMIT ❑6 TEMPORARY TANK CLOSURE ❑ ❑ MARK ONLY ❑ 4 AMENDED PERMIT ONE ITEM ❑2 INTERIM PERMIT .FARM TANK-YES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED' FY B. MANUFACTURED BY'. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT A. OWNERS TANK IDR D. TANK CAPACITY IN GALLONS'. C. YEAR INSTALLED ❑3 DIESEL TANK CONTENTS IF(A.1),IS MARKED, C. ❑ 1 UNLEADED ❑ 2 LEADED II. COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM ❑6 AVIATION GAS B 4 GASAHOL ❑5 JET FUEL A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM i .1 PRODUCT ❑ ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 7 METHANOL 1199 OTHER(DESCRIBE IN ITEM D,BELOW) ED]5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE C.A.S.q: LE FUEL,ENTER NAME D HAZARD OUSSUBSTANCE LOF STORED&CAS.R 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑95 UNKNOWN ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑99 OTHER NFORCED PLASTIC A.TYPE OF ❑4 SECONDARY CONTAINMENT SYSTEM ❑2 SINGLE WALLED 4 STEEL CLAD WIFIBERGLASS REI ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ ❑ I STEELIIRON 7 ALUMINUM ❑B IC6�'h METHANOL COMPATIBLE FRP B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 95 UNKNOWN ❑99 OTHER MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING ❑ i RUBBER LINED ❑2 ALKYD LINING ❑ ❑.g5 UNKNOWN C. INTERIOR F-15 GLASS LINING ❑6 UNLINED ❑ ❑ El OTHER LINING NO El LINING MATERIAL COMPATIBLE WITH 100%METHANOL4 YES 4FIBERGLASS REINFORCED PLASTIC ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP 0 9 UNKNOWN PROTECTION ❑ 5 CATHODIC PROTECTION El 91 NONE A U 3 GRAVITY A U 9 NE A U 95 UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE AIFpBUVPPROSUR UIFUNDERGROUND,BOTHIFAPPLICABL A. SYSTEM TYPE A u 1 sucnoN B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Af U, 95 UNKNOWN A U 99 OTHE A U 1 STEEL/IRON A U 8100%METHANOL COMPATIBLE FRP p U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE p U 91 NONE A L 6 CONCRETE A U 7 STEELCLAD W/FRP C.MATERIAL A U 5 ALUMINUM A U 99 OTHER A U 9 GALVANIZED STEEL A U,.95 UNKNOWN S 4 ELECTRONIC MONITOR p S 5 GROUND WATER MONITORING WELLS V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P j S 95 UNKNOWN P S 99 OTHER- p S I VISUALOHECK P S 2 INVENTORY RECONCILIATION P 5 91NONEWELLS P 5 6 PRECISION TESTING p S 7 PRESSURETESTING . . S FED VI. INFORMATION ON TANK PERMANENTLY CLOSED IN OF 3WATA NK ILLWITH IMATEG QUANTITYINERT MATERIALF ❑YES ❑ NO 1. ESTIMATED UPTE LAST USED(MO/VR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOOWTE DGE, IS TRUE AND CORRECT. APPLICANT'S NAME(( PINT D 8 SIGNATURE) LOCAL AGENCY USE ONLY TANK ID R FACILITY IDN COUNTY R JURISDICTION R AGE mPHONE p WITH PREP CODE APPROVED BY NAME CURRENT LOCAL AGENCY FACILITY IO N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER SURCHARGE AMT. FEE CODE RECEIPT# BY. CHECKN PERMIT AMOUNT FORM 'A',UNLESS A�,RRENT FORMA' HAS BEEN FILED FORM B(6-29-88) THIS FORM MUST BE ACCOMPAA J BY A FACILITY/SITE APPLIF'EOCOCOPY _