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STATE OF CALIFORNIP WATER RESOURCES CONTROZOARD FORM `B': UNDERGROUND STORAGE TANK PRO—u'ORAM TANK TANK PERMIT APPLICATION INFORMATION ®Iro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- _ MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 A. OWNERS TANK IDR I I B. MANUFACTURED BY: C. YEAR INSTALLED N( D. TANK CAPACITY IN GALLONS: /o II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM k IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CT1 A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADEDLEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑M EMPTY ❑95 UNKNOWN ❑2 STE�T,,d ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) CLE FUEL,ENTER NAME 0 IF HAZOT MOTOR AR OUS SUBSTIRNCE STORED 8 CA.S.ROF C.A.S.R: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B, ,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR J ER ❑95 UNKNOWN SYSTEM ❑-2-I EWALLED ❑4 SECONDARY CONTAINMFM ❑W OTHER I /I N ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81 DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING E4*-URINNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IDA%METHANOL? ❑YES ❑ NO ❑99 OTHER I D. CORROSION ❑.I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑9rNONE ❑ 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEELCLADW/FRP A U B /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95,UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 'Y� J P /6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES NO YAELONB I THIS FORM HAS BEEN COMPLETED UNDER.PENALTY OF PERJURY,AND TO THE BEST OF MY KNCSWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED SSIGNATURE) DATE l LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID R TANK ID N j UDo2, CURRENT LOCAL AGENCY FACILITY ID LtWROVED BY NAME PHONE Ii WITH AREA CODE 9 ?g PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E (RATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMe13-7-8e1 THIS FORM MUST BEACCOMPANI✓9AFACILITY/SITE APPLICATION, FORM `A',UNLESSA _,, RENT FORMA' HASBEENFILED 'ING COPY