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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD _ FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. „ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT D�e6HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O -1 I✓ FARM TANK•YES❑ NO •7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY j vv rJ A. OWNERS TANK IDp B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' Q 0 II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. US A. i MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED ❑2 LEADED 1kr3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �RODUGT ❑ 4 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 8 C.A.S.# C.A.S.#: =III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TANK ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FI8ERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE nyACUMINUM ❑B 1D0%METHANOL COMPATIBLE ERP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOUC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE MTH 100%METHANOL? ❑YES ❑ NO E]S9 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE EV5 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. 1A1 6 / VISUAL CHECK P B 2INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 00 1 / I = I(f' J CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA COBE , PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE jlRECEIPT# v✓� FORM B(3-7-68) THIS FORM MUST BE ACCOMPANIMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-CURRENT FORMA' HAS BEEN FILED y-Z'--f ly DATA PROCESSING COPY