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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM'B': UNDER-aROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ORCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:16 TEMPORARY TANK CLOSURE ANK REMOVED O 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN —SOSPECIFY A. OWNERS TANK ID P B. MANUFACTURED BY: C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL O YEAR INSTALLED D. TANK CAPACITY IN GALLONS. L� II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF MAI. IS NOT MARKED. COMPLETE ITEM D. / A_ VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL P�XOTOR 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 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 & C.A.S. R CAS. R: . III. TANK CONSTRUCTION MARY ONE ITEM ONLY IN BOX A, B, C,& D A. TYPE OF ❑ 1 DOUBLEWAUED N 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ SECONDARY CONTAINMENT ❑ 99 OTHER 6 1 ❑ 1 STEEL/IRON ❑ 25T LESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC r B. TANK ❑ 5 CONCRETE ❑ 6 POLYVI CHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANI STEEL ❑ 95 UNKNOWN ❑ 99 OTHER P RMIT EXPIRATION DATE ❑ i RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS UNING ❑ 6 UNUNEO ❑ 95 UNKNOWN PERNR AMOUNT ❑ IS LINING MATERIAL COMPATIBLE WITH 1011% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF NDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE 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 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECO DARY. A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH FACILITY ID A SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO = GALLONS 6 1 THIS R RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE ST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE T RRECT. COUNTY N JURISDICTION # AGENCY K FACILITY ID A TA)NK ID k aa = 6 1 TAV CURRENT A NCYFACILITYID• APPRO71 BY E ^ ^D �./1 PHONE R WITH AREA CODE PERMITN6M8ER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE CHECK M PERNR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: JTY A FACILITY/SITE API FORMA' HAS BEEN FILED FORM 8 (5 -z9 -Be) THIS FORM MUST BE ACCOMF DATA PROCESSING COPY —