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STATE OF CALIFORNIWATER RESOURCES CONTRC IOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % 3 PLETE A SEPARATE FORM WITH THE FOLLOWING I MATION FOR EACH TANK. - MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -401 FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A F� A. OWNERS TANK ID N 8. MANUFACTURED BY: (JT C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: -S-6z � IL TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AS),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. E]1 UNLEADED LEADED DIESEL 8. ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PppDUCT ❑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.N C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ "PAU WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2WAUED ❑4 SECONDNR'CONTAINMENT ❑ 99 OTHER STEEL/IRON F-12 STAINLESS STEEL F-13 FIBERGLASS ❑4 STERCIAO W/RBERG(ASS REINFORCED PLASTIC B.TANK 1 MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 AUAIIMIM ❑8 1OD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBER LINED ❑Z NG ❑3 EPDXYUNING ❑4 PHENOUCUNING LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHL£NE WRAP ❑2 TAR OR ASPHALT ❑3 VI 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNIDIONN 99 OTHER IV. PIPING INFORMATI CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SLI&I A U 2 PRESSURE A U 3 GRAVITY 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 TRENCH A U 91 NONEUNKNO A U 99 OTHER A U I 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 B A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P B 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 95 UNKN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INOALLONB 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) PATE LOCAL AGENCY USE ONLY COUNTY p JUmmSDICTIONN�N AGENCY p FACILITY ID p TANK ID p CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE a WITH MG CODE NN1g PERMIT NUMBER PERMITAPPLLOVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE ^CEIPT I BY qU FOHM B(6 29 66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY