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STATE OF CALIFORNI/ WATER RESOURCES CONTROL ')ARD FORM `B': UNDERGROUND STORAGE TANK PROMAM `r = TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z ,a MARK ONLY F—] 1 NEW PERMIT F—] 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 RMANENTLYCLOS K ONE ITEM 1:12 INTERIM PERMIT 1-14 AMENDED PERMIT ` ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 S, �� Q FARM TANK-YES❑ NO (A) CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ((� A. OWNERS TANK ID# Ir URED BY: F C. YEAR INSTALLED tq g() I D. TANK CAPACITY IN GALLONS: Q o II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Vl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED EL F—] 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT E]4 GASAHOL 5 JET lCJ FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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 A C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,AD A.TYPE OF DOUBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM � NGLEWAU.ED ❑4 SECONDARYOGNTAINMENT ❑99 OTHER Fm I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 P ENOUC LINING C. INTERIOR LINING ❑5 GLASS LINING F76 UNLINED 95 UNK N ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO THER D. CORROSION ❑ 1 POLYEfHLENEWPAP ❑ 2 TAR OR ASPHALT ❑3 VI LWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH I U 91 NONE A U 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 STEEL CLAD W/FOP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 5 UNKNOWN P 8 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 INERT MATERIAL? ❑YES ONO 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# p o 0 FCHECK* LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE N WITH AREA CODE UMBER �O PERMIT APPR VAL DATE �/I PERMIT EXPIRATION DATE /(� _ PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPTN FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANRwd A FACILITY/SITE APPLICATION, FORM `A',UNLESS R.owi1RENT FORM'A' HAS BEEN FILED l DATA PROCESSING COPY