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STATE OF CALIFORNIA WATER RESOURCES CONTROL -OARD FORM `B': UNDERGROUND STORAGE TANK PROGFFiAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION YPERMANENTLY CLOSE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 10 (AT FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 FARM TANK-YES 0 NO W F I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY `T 00 A. OWNERS TANK ID# B. MANUFACTURED BY: G C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A 1900 IL TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM C. ❑1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A TYPE OF ❑ SYSTEM ty 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 81 METHANOL COMPATIBLE /Q MATERIAL �/ Q ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER�P ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PP NOUC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED L�jIJ-'9955 U WN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT 3 VINY RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFOR MA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE AeU.1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A CONCRETE A U 7STEEL CLAD W/FAP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 NODOSE WELLS P 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE 8 95 UNKNOWN P S W 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 INERT MATERIAL? ❑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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � I '799 vv3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE TD 5� PFRMIT NUMBER PERMI OVAL DA PERMIT EXPIRATION DATE i� ICHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE I ^ECEIPT# BY�f FORM B(8-29-88) THIS FORM MUST BE ACCOMPWD BY A FACILITY/SITE APPLICATION, FORM 'A',UNL CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY