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STATE OF CALIFOR0 WATER RESOURCES CONT. BOARD FORM B': - -UNDERGROUND STORAGE TANK PROGRAM R.� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z �u MARK ONLY '-❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED-TANK ' ONE ITEM ❑21NTERIM PERMIT ❑ 1 AMENDEDPERMIT ❑ 6TEMPORARY TANK CLOSURE �BTANKREMOVED FACILITYASITE NAME WHERE TANK IS INSTALLED: L/ �,'-.r ? r, FARM TANK-YESA❑i NO ❑ N L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY S ! (1J A OWNERS TANK IDN i R. MANUFACTURED BY: C. YEAR INSTALLED (; 'L D. TANK CAPACITY IN GALLONS: G f� 7 II. TANK CONTENTS IF(A1),13 MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ /OIL ❑ 1 PRODUCT ❑ A GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C.BD A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEA ❑95 UNKNOWN SYSTEM. ❑ 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEFLIRON ❑2 STNNLESSSTEEL ❑3 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGIASS REINFORCED PLASTIC S.TANK _❑5 CON(AETE ❑6 POLYVINYLCHLOINDE ❑ 7 ALUMNA ❑610D%METHANOL COMPATIBLE FRP MATERIAL. :_ ❑9 BONZE ❑ 10 GALVAN12EO STEEL ❑95 WIKIIOWN ❑99 OTHER ❑ I RIIBBERUNED ❑2 ALKYOUNING E]3 EPDXY UMNG ❑A PHENOLIC LINING C. INTERIOR INK G R ❑5 GIM LINING ❑6 UNLINED ❑95 UNKNOWN ISUNING MATERIAL CDMPATIBLE WITH IDD%MERiAla? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYERILENEWRAP ❑2 TM OR ASPHALT ❑3 VINYL WW ❑/FIBERGIASSREINFORCEDPUSTIC PROTECTION: ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 95 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERUL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP 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 f 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P t A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS t 6 PRECISION TESTING P 1 7 PRESSURE TESTING P t 91 NONE P f 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FA7 ID N _ APPROVED BY NAME PHONE 9 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CXECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT If B7: w �.�- FORMB(S-29-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED