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STATE OF CALIFORNII WATER RESOURCESCONTRO' 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAMAa` TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N W I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY OJ A. OWNERS TANK ID M b B. MANUFACTUREDBY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OL 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED D4DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY E:]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 N BOX A,B,C,&D A.TYPE OF ❑ 1 BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AL IMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PI510UCUNIMG C. INTERIOR LINING [__j5 GLASSUNING ❑6 UNLINED lz 95 OWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO 990THER D. CORROSION ❑I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E]M NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A CTI SUON A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A JUA SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 01 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUALCHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMAT DATE LAST USED(MO/YR) 2. ESTIM ED QUANTITY OF 3.WA TANKFILLEDWITH N REMAINING IN DILLLONS IN /41ATERIAL7 [-]YES ❑ NO THIS FbRm HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# in 3I vov CURRENT LOCAL AOENGY FACILITY ID APPRO EP 6Y NAy[� PHONE WITH AREA CODE L` /� /`(JS 8 -lv/ CL I/J 7 PERMIT NUMBER PER VAL AIfE �. PERMIT EKPI ON DATE (�Q�V,�/ CHECK N PERMIT AMOUNT SURCHAR E AMT. FEE CODE RECEIPT# BY: FORM R(6-29-88) THIS FORM MUST BE ACCOMPANIEDvY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS At"RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY