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STATE OF CALIFORN17 WATER RESOURCESCONTRC IOARD FORM `B': UNDERGROUND STORAGE TANK PROURAM �. TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLpBEB1TANK (d ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVEL_C/f/J FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES ff NO ❑ � N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID Rp B. MANUFACTURED BY: L(ilL N C. YEAR INSTALLED LilorD. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AT),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 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 ,1❑/,9/5 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.R C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DDUBLEWAUD ❑ 3 SINGLE WALLED WITH EXTERIOR UNEP95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLA&R REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ NUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ CUNING LINING ❑5 GLASS LINING ❑ 6 UNLINED95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 109KMETHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3^WRAP ❑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 t SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 9 UNKN WN U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UN OWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBER PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U BQQNBRRE� A U 7 STEEL CLAD W/FAP A U B 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 9 UNKN W 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 IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4E NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 5 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 5 UNKNO N P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANATY OF GALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [DYES ❑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 I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY N FACILITY ID k TANK ID k 3 q `t 3 0 3 o 10 CU NT CAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE II�J CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: V"I FORM B(6-29-88) C� THIS FORM MUST BE BY AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY