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STATE OF CALIFORN11 WATER RESOURCES CONTROI ')ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - - Z 10 I MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT [:]5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS ONE ITEM F-] 2 INTERIM PERMIT F--] 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 03 171 E TMe e. FARM TANK-YES❑ NO w W IU I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: � C C. YEAR INSTALLED ! D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL I r7 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM 2 SINGLE WALLED SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 L'S' STEEL FIBERGLASS FIBERGS F74 STEEL CLAD WIFlBERGUSS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ID POL IECHLORIDE F-17 ALUMINUM E]8100%MMMOLCOMPATI8LEFRP 9 BRONZE ❑ 10 GALVANI STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. LILINING ❑5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER II D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHAL7 E VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 NOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFASOVEGROUND, U IF UNDERG UND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUREA U 3 1 ITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED NCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL LORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/ P A U 8 100%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 EAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P IS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS(P JP 4 ELECTRONIC MONITOR P IS 5 GROUND WATER MONITORING WELLS 9•"O)� P B 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE �S 95 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 [:-]: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 LOCAL AGENCY FACILITY ID F APPROVED BY N`AM PHONE 0 WITH AREA CODE o PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPAN..BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS- BRENT FORMAHAS BEEN FILED DATA PROCESSING COPY -5