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STATE OF CALIFORNI. _ WATER RESOURCES CONTR( IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION (oz COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 7 P RMANENTLY CLOSED TANK IC MARK ONLY F-1 ❑ ❑1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO N N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY cm A. OWNERS TANK ID# y I B. MANUFACTURED BY: u cc C. YEAR INSTALLED , D. TANK CAPACITY IN GALLONS: / /00 II. TANK ONTENTS IF(A.1),IS 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 E]3 DIESEL F-13 CHEMIGALPRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JEF FUEL ❑6 AVIATION GAB ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.If C.A.S.#: Ill. TANK CONSTRUCTION MARKONEYFEMONLYINBOXA,B,C,SD A TYPE OF ❑ 1 DOUBLE WALLED 3 SNGLEWALLED WITH EXTERIOR LINEA 2Trss UNKNOWN SYSTEM ❑2 SIDLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELPRON ❑2 STAINLESS STEEL ❑ 3 RBENGLASS ❑4 STEEL CIAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B t00RMETHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNE ❑2 ALKYD LINING E]3 EPDXYLINING ❑4 PHENOLIC LINING C. NTT LINNRGOR ❑5 GLASS LINING ❑6 UNUNE UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IWR METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYEfHLENEWRAP 2 TARORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑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(UJ5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 STEELCLAD W/FRP A U S 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Aj U>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 8 2 INVENTORY RECONCILIATION P 8 3 E WELLS P 8 4 CMONITOR P 8 5 GROUNDWATER MONITORING WELLS P 8 fi PRECISIONTESTING P S 7 PRESSURETESTING 8 91 NONE P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PL CE 1::,ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH j 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# CURRENT LOCCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATV APERMIT EXPIRATION DATE III CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY: FORM B(6-29-aB) THIS FORM MUST BE ACCOMPANIEalVA FACILITY/SITE APPLICATION, FORM 'A7,UNLESS AMRENT FORMA' HASBEENFILED DATA PROCESSING COPY