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!jj STATE OF CALIFORNIA WATER RESOURCES CONTR ARD ° UNDERGROUND STORAGE TANK PROG AM FORM `B': TANK PERMIT APPLICATION INFORMATION THE FOLLOWING INFORMATION FOR EACH TANK COMPLETE A SEPARATE FORM WITH ]❑7 PERMANENTLY CLOSED TANK ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 NEW PERMIT ❑8 TANK REMOVED MARK ONLY q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM ❑21NTERIM PERMIT ❑ FARM TANK-YES❑ NO ❑ ?.r FACILITY/SITE NAME WHERE TANK IS INSTALLED: (,-b FY I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ANUFACTURED BY: A. OWNERS TANK ID p D. TANK CAPACITY IN GALLONS'. C. YEAR INSTALLED IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ❑3 DIESEL II. TANK CONTENTS B c ❑ 1 UNLEADED ❑ 2 LEADED A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ❑ � PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT 11 ❑ 4 OIL 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ BO EMPTY El95 UNKNOWN E] 2 WASTE C.A.S.R' LE FUEL.ENTER NAME D HAZAARDOU9 SUBSTIANCE STORED&C.A.S.MOF IF NOT M 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX 8 D ❑ 95 UNKNOWN A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT SS ❑ 2 STAINLESS STEEL ❑3fIBERGlA45TEEL CIADWIFIBEPGLASS REINFORCED PLASTIC 11 STEEUIRON ❑ ❑0100%METHANOL COMPATIBLE FRP B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM 99 OTHER El 9 BRONZE MATERIAL ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING F-11 RUBBER LINED ❑ 2 ALKYD LIVING ❑'"g5 UNKNOWN C. INTERIOR F-15 GLASSUNING 116 UNLINED LINING ❑ ❑ NO F-199 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 V,INYLWRAP F-1 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �95 UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLEAONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U 1 SuGT'ON A. u 2 PRESSURE - B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENGH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U ] SOTEELICLAD W/NYL ORPDE(PVC) R U B FW%METHANIBERGLASS IOL COMPAPE A TIBLE FRP 91 NE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE 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. P S 4 ELECTRONIC MP S 95 UNKNOWN P S 99 OTHER P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VNOONEE WELLS MONITOR P S S GROUND WATER MONITORING WELL P S 6 PRECISION TESTING P S 7 PRESSURETESTING VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? DYES ❑ NO I. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODWTE LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) LOCAL AGENCY USE ONLY FACILITY IDR TANK ID F COUNTYR JURISDICTION R AGENCY R71 mAPPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER SURCHARGE AMT. FEE CODE ECEIPT# BY: CHECKM PERMIT AMOUNT FORM ,A%UNLESS A wRRENT FORMA' HAS BEEN FILED FORM B(6-29-6B) THIS FORM MUST BE ACCOMPAN.ED BY A FACILITY/SITE APPLICATION, COPY