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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE'TANK PROGRAM - o TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G ❑3 RENEWAL PERMYT ❑I 5 CHANGE OF INFORMATION '❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ 1 NEW PERMIT TANK REMOVED E ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FARM TANK-YES NO FACILITY/SITE NAME WHERE T K IS INSTALLED: C® 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY AB. MANUFACTURED BY: . OWNERS TANK ID# a�4 l i D. TANK CAPACITY IN GALLONS: C1 GV C C.YEAR INSTALLED II. TANK CQNfENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 17. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B . C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ('�1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL L�J i ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ,I ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) i la D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D ; I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR LINER {E ,, UNKNOWN A.TYPE OF ❑ []ss OTHER t SYSTEM F-12 SINGLE WALLED ❑4 SECONDARY CONTAINMENT r ❑ I STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS�! ❑4 STEELCLADWlFIBERGLA55REINFORCEDPLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-1T ALU € ❑6 lIXN6 METHANOL COMPATIBLE FRP ❑ - MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN'. ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYOLINING ❑ 3 EPDXY LINING ❑4 PHEN INING C.INTERIOR 5 GLASSUNING 6 UNLINED UNKNOWN LINING � � - ❑IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? DYES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VI P.j F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 U91 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 STEELIIRON A U 2 STAINLESS STEEL A U 3'POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 7 iSTEEL CLAD W/FRP A U. 8 100%METHANOL COMPATIBLE FRP C.MATERIAL A U 5 ALUMINUM A U .¢CONCRETE A U 9 GALVANIZED STEEL A(205 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 $ 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P $ 3 Vi WELLS.0 P 6 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WEILS P S 99 OTHER P S 6 PRECISION TESTING P $ 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED OUANTITY OF r1 3.WAS TANK FILLED WITH 7F1. ESTIMATED DATE LAST USED MOIYR) SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO t. GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) - € f LOCAL AGENCY USE ONLY f F FACILITY ID# TANK ID# COUNTY# JURISDICTION# AGENCY# I I Li I Ll PROVED BY N E PHONE N WITH AREA CODE CURRENT LOCAL A`rG��ENCY FACILITY IDN APy V € ! 110 ID PERMIT NUMBER PERMIT APPROVAL DATE ER IT EIIPIRA PATE CHECK N PERMIT AMOUNT SURCHARGE AVT. FEE CODE CEfPT�N BY: �'rt- -* �_,,,,_-_ .,,,,.••,,or.r,..erasss��.,,yx_a eArn lTvrctTc HAS BEEN FILED ,APPLICATION. FORM �A',UNLESS A t;v lRENT_,FQRM'A'-