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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED 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 ❑ •� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED L, D. TANK CAPACITY IN GALLONS: 0 Q 11. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. L] l 1 UNLEADED ❑2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 0 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&CAS.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESSS'TEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 INUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELff UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINE ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 P LICUNING LINING ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINY P ❑4 FIBERGLASS REINFORCE PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIFABOVE GROUND, UIFUNOERGROUND,BOTH IFAPPLICABLE 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 ArUJ95 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 ALUMINUMA U 6 CONCRETE A U 7 STEELCLADW/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. - �,II P t 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 V E WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS '�Vn�AJ� P t 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P 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 INGALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# M QZ] I o lo l 1010101 CURREN OCAL AGENCY FACILITY ID JL,., APPROVED BY NAME 1/p PHONE#WITH AREA CODE /`%J /( / i PERMIT NUMBER PERMIT APPROVAL DATE PERMIJ EXPIRATION DATE CHECI PERMITAMOUNT MIRCHARGEAMT. FEE CODE RECEIPT# BY: I FORM a(6-29-ee) THIS FORM MUST BE A=WA AF /SITE APPLICATION, FORM 'A',UNLESS X.00RE RM'A' HAS BEEN FILED DATA PROCESSING COPY