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STATE OF CALIFORNI! WATER RESOURCES CONTRO'_'DARD FORM 'B': UNDERGROUND STORAGE TANK PROGAAM TANK TANK PERMIT APPLICATION INFORMATION m ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSED TAN (� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Lo D FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# B. MANUFACTURED BY: �// J . C. YEAR INSTALLED G( D. TANK CAPACITY IN GALLONS'. /oinoa II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS OT MARKED,COMPLETE ITEM D. A. EVI MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. O- El UNLEADED E]2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 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 8 C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1 DOABLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMI UM ❑8108%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑18 GALVANIZED STEEL L&WSNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNE ❑ 2 ALKYD LINING E]3 EPDXY UNING ❑ 4 PH LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH Ion METHANOL? ❑YES ❑ NO ❑ 99 OTHER I D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINY P ❑ 4 FIBERGLASS REINFORCE FUSTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONEUNKNOWN ❑ 99 OTHER II 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 Aa 95 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 UNKNOWN A U 99 OTHER A U 1 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 A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 WELLSP 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 8 91 NO 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 DALLONS INERT MATERIAL? ❑VES ❑ 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# \� CURRENT LCMENCY FACILITY ID APPRQYEV BY NAME PHONE#WITH AREA CODE UUUU\1 F- PERmrrNuiftm PERMIT APPROVAL DATE �ERMITEXPIRATION DATE `\ 7 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-9B) THIS FORM MUST BE ACCOMPANIED BY A�FACILRY/SITE APPLICATION, FORM 'A',UNLESS A CURR T FORMA' HAS BEEN FILED DATA PROCESSING COPY