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STATE OF CALIFORNF WATER RESOURCESCONTR/ 30ARD FORM 'B': // UNDERGROUND STORAGE TANK PROGRAM TANK Li' 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 P ANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT '' / ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: w. �j /yO3� FARM TANK-YES NO ❑ e O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY r� 9'w A. OWNERS TANK ID B. MANUFACTURED BY: w C. YEAR INSTALLED D. TANK CAPACITY IN GALLON ' O T„ II. TANK CONTENTS IF(AT),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, PLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS Ii ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM 0,BELOW) . 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.# C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN SYSTEM ❑2 SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SIEFLIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 SM CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUM" ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELrj>'lM<NOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RIBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY UNING n 4�PAENO LINING LINING ❑ 5 GLASS UNING ❑6 UNUNED 95 MOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IDG%METHANOL? ❑YES ❑NO OTHER D. CORROSION ❑ 1 POLYETHLENEWPAP ❑2 TAR OR ASPHALT ❑3"P ❑4 RBERGLASS REINFORCED PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE L&K 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 U 3 GRAVITY A U 91 NONE A 9 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 tU 96 UNKNOWN A U 99 OTHER A U 1 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 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS Ar P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 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 INERTMATERIAL? ❑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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FA - TANK ID# I 4d CURRENT LOCAL AGENCY FACT R APPROVED BY NAME PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# I . FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY