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STATE OF CALIFORNIP WATER RESOURCES CONTROL -)ARD FORM `B': UNDEltdROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO DTANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED III N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 FARM TANK-YES❑ NO CJ1 b7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# I C B. MANUFACTURED BY: C. YEAR INSTALLED L.e tk, I D. TANK CAPACITY IN GALLONS. 5-00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P TROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL 1 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1DOUBLE 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 F18EAGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RU68ER LINED ❑2 DLINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 U INED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 ETHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR NHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GRO D, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSU 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 W D 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 STAINLESSSTL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBEAGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 FO SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WEL S P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 3 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 OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INOALLONB INERT MATERIAL' ❑YES E] 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# F37 I I I / Io o i o CURRENT LOCAL AGENCY FACILITY IO# APPROVED D BY N ME Y/f� PHONE#WITH AREA CODE 35I qflm� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED. _ .;ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CLs:RENT FORMA' HAS BEEN FILED :NOCESSING COPY