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STATE OF CALIFORNI WATER RESOURCES CONTRL 30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK ` TANK PERMIT APPLICATION INFORMATION C1-4�OMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I NEW PERMIT 3RENEWAL PERMIT 5 CHANGE OF INFORMATION 7P MANENTLY CLOSED TANK )c MARK ONLY ❑ ❑ ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT [:]4 AMENDED PERMIT ❑B TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES ERO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W W A. OWNERS TANK IDR B. MANUFACTURED BY: 6d C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF WI),IS MARKED,COMPLETE ITEM C.IF(A1),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 La/ ❑ 1 PRODUCT ❑4 GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑ 2 WASTE E]7 METHANOL -]99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7AfUMINUM ❑8 100%METHANOL COMPATIBLE RIP MATERIAL F-19 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2ALKYD LINING ❑3EPDXY LINING ❑ ENOLIC LINING LINING F-15 GLASS LINING ❑6 UNLINED "KNOWN �� /�� ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER 1&td - D. CORROSION ❑1 POLYETHLFNE WRAP ❑2 TAR OR ASPHALT ❑3 YINYLWRAP ❑ 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 / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A a95 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 A&195 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 17 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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS N P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEDATE LAST USED(MO/YR) 2. UBM ^ MYOFIN GALLONS WAS ANK FILLED WITH VIA 42- ATERIAL? [--]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&SIGNATURE) I DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0 10 1 1 0= I CIO CURRENT LOCAL,AO N Y FACILITY IDR yF,D M PHONE N WITH AREA CODE / ICH PERMIT NUMBER 3 PERMIT APPROVAL DATE(Jr// PE IT EXPIRATION DATE / ECKN PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: ��IIIIVVV11MMM/// FORM B(6-29�) THIS FORM MUST BE ACCOMPANIE15TY A FACILITY/SITE APPLICATION, FORM'A',UNLESS AZIGRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY