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yr CALIFORN' . FORM `B': WATER RESOURCES CONTF BOARD UNDERGROUND STORAGE TANK PRTGRAM TANK TANK PERMIT APPLICATION INFORMATION = a . COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK: MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 7 PERMANENTLY CLOSE 2 INTERIM PERMIT �4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY •O A. OWNERS TANK ID# J B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.i),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRppUp7 ❑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.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A. TYPE OF ❑ ID�UBLE WALLED F-13 SINGLE WALLED WITH EXTEROR UNER ❑95 UNKNOWN SYSTEM ��1SING WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS [-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM E]B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED [-]2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C, INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED [UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IOU%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 T ASPHALT ❑3 VIWLWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ER'91 NONE ❑95 UNKNOWN ❑99 OTHER -' IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE AW 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 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL Atl�5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6 IGO%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. L��I P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P E WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUNDWATER MONITORING WELLS `�° P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NO P S 95 UNKNOWN P S 99 OTHER 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 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# E41 3 P/I lo b 163 1 / L CURRENT CAL AGENCY FACILITY ID# APPROVED BY NAME a-D PHONE#WITH AREA CODE hal I/ 3 V PERMIT NUMBER PERMIT APPROVAL DATE PERMI 0 EXPIRATION DATE 1. (J / CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V� FORM B(6-29-89) THIS FORM MUST BE ACCOMPANIED BY 4 FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C'UAENT FORMA' HAS BEEN FILED DATA PROCESSING COPY