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STATE OF CALIFORNI WATER RESOURCES CONTRF IOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK MARK ONLY ❑ I NEW PERMIT 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION I J / P NENTLYCLOSEDT NK to ONE ITEM ID INTERIM PERMIT 4 AM ENDED PERMIT E]6 TEMPORARY TANK CLOSURE TANK REMOVED p FACILITY/SITE NAME WHERE TANK IS INSTALLED: i FARM TANK-YES NO ❑ L71 N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY f A A. OWNERS TANK ID# u B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),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 ❑ 1PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AWATIONGAS ❑5 HAZARDOUS ❑80 EMPTY 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 CA.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A.TYPE OF ❑i DOUBLEWALLED ❑3 SINGLEWALLEDWITHEXTEAIOR LINER 95 UNKIIDWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RSERGLASS REINFORCED PLASTIC S. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 MATERIAL A NUM ElB 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR 171 RIBBERUNED ❑2 ALKYD LINING 3 EPDXY UNING ❑4 PH UC UNING LINING ❑5 GLASS LINING F-16 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%MEfHANOL? ❑YES ......❑ NO [-]99 OTHER D.CORROSION F-1I POLYETHLENEWRAP ❑ 2 TARORASPHALT F-13NNNNNNtWWWRMPRM�AAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROnMON ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A VO JB5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALIFD A U 3 LINED TRENCH A U 91 NONE UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&_)5 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P B 1VISUAL CHECK P S 21NVENTORY RECONCILIATION P S EWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK RULED WITH OALlON3 SUBSTANCE REMAINING IN 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# .oI = = 175b 1 101010131 CURRENT LOCAL AGENCY FACILITY ID x APPROVED BY NAME PHONE#WITH AREA CODE SL PERMIT NUMBER PERMIT APPROVAL DA RMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEUVY A FACILITY/SITE APPLICATION, FORM'A',UNLESS ACITRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY