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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�Q7ANNI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ©8 TANK REMOVED / / FACILITY/SITE NAME WHERE TANK IS INSTALLED:7(-/'7 FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID 10-l/ B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: CA) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. sD A UZI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. � C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL e'1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# AJA C.A.S.#: .III. TANK CONSTRUCTION MARK ONII ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN 2 SINGLE WALLED 0 ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEBUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFOEDEDPUISTIC B.TANKF-1 5 CONCRETE ❑fi POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL [—]9 BRONZE ❑ 10 GALVANIZED STEEL [—]95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑1 RUBBER LINED ❑2 DLINING ❑3 EPDXY LINING ❑4 PHENOLIC UNI NO LINING ❑5 GLASS LINING 6 UNUNED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH R00%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2TAR OR ASPHALT ❑3V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A Q1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A Wl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 5 UNKNOWN A U W OTHER V.—LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. � I'D P S 1 VISUAL CHECK INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P' P S 6 PRECISION TESTI S ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTIMATED PUANTITY OF 3.WAS TANK LLED WITH SUBSTANC fl MAIMING IN GALLONS INERT M T AL? ❑YES ❑ NO THIS FO M HAS BEEN COMPLETED UNDER PENALTY OPPERJURY,AND TO THE BEST OF MY KNDWLED E,IS TRUE AND CORRECT " APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID R UE = = 1 D 1 O D - " DO 10 Z CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE#WITH AREA CODE LPERMITNUMBER PERMIT APPROVAL DATE R 1 PIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-se) THIS FORM MUST BE ACCOMPANIReY A FACILITY/SITE APPLICATION, FORM 'X,UNLESS RENT FORMA' HAS BEEN FILED "-iC SSING COPY