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STATE OF CALIFORNII, WATER RESOURCESCONTRO' OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM " ` TANK TANK PERMIT APPLICATION INFORMATION ' } o COMPLETE A SEPARATE FORM WITH THE FOLLOWIr INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT t 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 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❑ evq I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID a B. MANUFACTURED BY: (1 C. YEAR INSTALLED 1612 D. TANK CAPACITY IN GALLONS: 12L00 0 W H. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Fl C ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS80 EMPTY ❑95 UNKNOWNASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.R: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 1�2 S,10 WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑ 3'FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE n �11LUMINUM ❑ 8188%METHANOL COMPATIBLE FRP MATERIAL L�y�( ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING 4 NOCK LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(U i SUCTION A U 2 PRESSURE A U 3 GRAVITYA 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(09f) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A y, 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. O/ S 1 VISUAL CHECK 0 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 7 P S 6 PRECISION TESTING PP S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN (ULLONS INERT MATERIAL? ❑YES E] 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 k JURISDICTION k AGENCY k FACILITY ID N TANK ID k 0 © b OOH CURRENT LOCAL AGENCY FACILITY IO k APPROVED BY NAME PHONE;-WITH AREA CODE j � Lz/, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTM BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PR' 'SING COPY