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STATE OF CALIFORNIA WATER RESOURCES CONTROL P')ARD FORM `B': UNDERGROUND STORAGE TANK PROGnAM TANK TANK PERMIT APPLICATION INFORMATION `mom COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ___- Z MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION El7 PERMANENTLY CLOSjgQj4K 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /Z1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N N A. OWNERS TANK ID p � � B. MANUFACTURED BY: C. YEAR INSTALLED L, D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 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&CAS.p a .e Q / CAS a. j Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.8 D A. TYPE OF ❑ I DOUBLEWALLE ❑3 SINGLE WALLED WITH EXTERIOR LINER95 UNKNOWN SYSTEM ❑2 SINGLE WALL® ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑i STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 AL W MATERIAL UM ❑6100%METHANOL COMPATIBLE.FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑H99 OTHER_ - -_ C. INTERIOR ❑ 1 RUBBER LINE ❑2 ALKYDUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING F-15 GUSSUNING ❑6 UNLINED 5 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 9OTHFA �c D. CORROSION ❑I POLYETHLENEWRAP ❑2 TARORASPHALT ❑ 3 VINY WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A&Uh GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A Q95 UNKNOWN A U 99 OTHER A U1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 A095 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. �j P S 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE I. 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION N AGENCY N FACILITY IDM TANK ID p CURRENT LOCALAGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 3 _ PEAMI NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE 4CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: )AIl"(6-29-81) THIS FORM MUST BE ACCOMPANIL'.;Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A„ RENT FORMA' HAS BEEN FILED