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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY /21N 1 EW PERMIT IM RENEWALPERMIT CHANGE OF INFORMATION El PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3(0,50 FARM TANK-YES❑ NO a► F.► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# L)ZF-,- B. MANUFACTURED BY: tiJ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CGNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Pj"l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OILPRODUCT ❑ 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO1(A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH DTEROR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLS ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑ 2STAINLESS STEEL ❑3FlBEAGlASS ❑4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZE STEEL ❑95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ I RUBBER LINE ❑2 A LNG ❑ 3 EPDXY USING ❑4 PHENOUC UNING LINING ❑5 GLASS LINING UNUNE ❑95 U MOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-] NO OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TWlRASPHALT ❑3 VINYL WRAP ❑4 F18ERGLASS REINFORCE PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 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 0>95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18ERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM AU fi CONCRETE A U 7 STEEL CLAD W/FRP A U 8 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P S 1 VISUAL CHECK P 8 2 INVENTORY RECORCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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( O/YR) 2. ESTIMATED OUANTITY OF3.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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = CURRENT AGENCY FACILITY ID# APPROVED BE � PHONE#WITH AREA CODE 3 Y N M3 PERMIT NUMBER PERMIT APPROVAL DATE PE 741TE PIR 1 N DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FOPM B 1529-BBI THIS FORM MUST BE ACCOMPANIEbVY AFAOLRYASITE APPLICATION, FORM 'A',UNLESS A" RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY