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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': / UNDERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. - _- z i0 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 1vf 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCL K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [_]0 TANK REMOVED , FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES[:] NO 4b. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANKID# B. MANUFACTURED BY: 00 C. YEARINSTALLED O. TANK CAPACITY IN GALLONS: II. TANKSZONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A. ,IS NOT MARKED,COMPLETE ITEM D 1 MOTOR VEHICLE E] 1 A F-]3 G EMICAL PR DUCTL E] 4 OIL ROLEUM B 1 PRODUCT C ❑4 GASAHOLO ❑ 5 JET FUEEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,•D A. TYPE OF ❑ t UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDEn�UMINUM ❑ 81 ON METHANOL COMPATIBLE RIP MATERIAL ��m"'JJJ/ ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ENOLICUNING LINING ❑ 5 GLASS LINING ❑6 UNUNEO 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES NO Fo"99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT n,TVINYL WRAP ❑4 RBERGIASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE LLLlJCJJ f95 UNKNOWN ❑99 OTHER i. IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE I A.SYSTEM TYPE AD i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 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 STEELCLADW/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION S STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. l 8 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ,l r✓/_l 8 6 PRECISION TESTING 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER u VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONB 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE 0/4 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED dY A FACILITY/SITEAPPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED(/ DATA PROCESSING COPY