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STATE OF CALIFORN' WATER RESOURCES CONTRI_30ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM '1 .. TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - - z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED aTA ONE ITEM F-] 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / W FACILITY/SITE NAME WHERE TANK IS INSTALLED: Qo FARM TANK-YES NO ❑ N Ln I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY,/ to A. OWNERS TANK ID# # I I B. MANUFACTURED BY: Ln C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: rti1- �Q II. TANK CONTENTS 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 ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ i 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 d CA.S.9 C.A.S.F. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A,D A.TYPE OF ❑ 1 OOU WALLED ❑ 3 SINGLE WALLED WITH D(TERIOR UNER ❑ 95 UNKNOWN SYSTEM NGLF WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER EUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 TIUBBERUNED ❑2 ALKYD UNING F73 EPDXY LINING ❑4 PHENOLIC LINING / LINING ❑ 5 GLASS LINING �'6 UNUNEO ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAARRORASPHALT F-13VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION - ❑'71 NONE ❑95 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 95UNKNOWN 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NO 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 OF 3.WAS TANK FILLED WITH 60 c'— SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES O THIS F RM 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 N JURISDICTION N AGENCY N FACILITY ID R TANK ID N DD � (b 10 I CURRENT OCAL AGENCY FACILITY ID N "PROVED BY NAME T T� PHONE N WITH AREA CODE V — V\ PERMITN MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ^, FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A*,WLITY/311E APPLICATION, FORM 'A',UNLESS A CURB FORMA' HAS BEEN FILED JV DATA PROCESSING COPY