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STATE OF CALIFORNI WATER RESOURCES CONTRC _'OARD FORM 'B': UNDERGROUND STORAGE TANK PROs RAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION Ll7 PERMANENTLY CLOSED TANK ONE ITEM El2INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I x FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 El% FARM TANK-YES NO ❑ AO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 61 0 A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED t D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, MPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 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 CAS.M C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑1 DOUBLEWALLED ❑3 SINGLE WAILED WITH EXTERIOR LINEA 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 RBE IGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B•TANK � ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F17 ALUMINUM ❑B 100%METHANOL COMPATIBLEFRP MATER ❑9 BRONZE ❑ 10 GALVANIZED STEEL F2 r95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING n 4 RJE14OLIC UNING C LININGER ❑5 GLASS LINING ❑6 UNUNED ,�,9`UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT n 3 yWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE IL±frgS95 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 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 U 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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� P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S OSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 1` P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING PC 8 91 NOW P 8 95 UNKNOWN P 8 99 OTHER 1• VI. INFORMATION ON TANK PERMANENTL OSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2. ESTIMATEDOUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E-]YES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID# TANK IO# D O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAAN ye PHONE N WITH AREA CODE �I oad PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXPIRATION DATE CHECK, PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPUCATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED -)ATA PROCESSING COPY