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STATE OF CALIFORNI! WATER RESOURCES CONTRO 'OARD FORM 'B': UNDERGROUND STORAGE TANK PRO RAM T .. TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INJIFOAMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED IS FACILITY/SITE NAME WHERE TANK IS INSTALLED: - FARM TANK-YES❑ NO z 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: t- IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMFCETE ITEM D. W N A. Cji MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED, ❑3 DIESEL co ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT E]4 GASAHOL ❑ 5 JET FUEL ❑fi AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN E]2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF j HAZARDOUS SUBSTANCE STORED&C.AAS./:,,, C.A.S.#: �- KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,4 a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER5 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECOM)ARYCONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON LP ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONC ❑6 POLYVIWLCHLO91DE ❑7AL UM ❑8100%METHANOL COMPATIBLE FOP MATERIAL ❑9 BRONZE 10 GALVANIZEDSTEELLL�f UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PH UC UNING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ] ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES EerNO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 VI LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE LIJ4 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 99 OTHER Uh, B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIRERGLASSPIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE 'A U 7 STEEL CLAD W/FRP A U B I0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM:. CIRCLE P FOR PRIMARY,OR$ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK $- 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US D(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FkILLEp*FTH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HASIBEEN COMPLETED UNDER PENALTY OF PER URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRIMED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3ik 10 1 t I v I n 10v CURRENT LOCAL AGENCY PACK. ID APPROVED BY NAM HONE N WITH AREA CODE UO PERMIT NUMBER PERMIT APPR VALIDATE #ERMIVkXPIRATIOVATE ICHECK# PERMIT AMOUNT SURCHARGE AM71 FEE CODE RECEIPT# BY: W/ FORM 8(3-7-68) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CL,,MENT FORMA' HAS BEEN FILED