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TATE OF CALIFORNI ♦ WATER RESOURCES CONTRC- 130ARD FORM 'B': UNDE11GROUND STORAGE TANK PROGRAM ` x TANKTANK PERMIT APPLICATION INFORMATION ANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T �= ZO MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 6 TANK REMOVED /Y1 N 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: K C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.l),IS NOT MARKED,COMPLETE ITEM D. A. Ugt MOTOR VEHICLE FUEL -12 PETROLEUM B. C. ❑ 1 UNLEADED �22 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A.TYPE OF ❑1 DOUBLE WALLED ❑ 3 SINGLE WALLED WRH EXTERIOR UNER 6d95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SfEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FAP MATERS ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑5 GlASSUNING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS UNING MATERIAL COMPAABIEWRH 100%METHANOL? ❑YES ❑NO �99 OTHER D.CORROSION ❑ I POLYETHLENEWPAP ❑2 TAOORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 5 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 A U 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 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 8 3 VADOSE WELLS tAS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 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 SUBSTANCE REMAINING IN GALLONS 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# F-3-a p09o83 00 z CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME Q PHONE N WITH AREA CODE S O PERMIT NUMBER PERMIT APPROVAL DATE ERMI EXPIR ON DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE °ECEIPT0 BY: S FORVBIe-29-56) THIS FORM MUST BE ACCOMPAN1Eb BY A FACILITY(SITE APPLICATION, FORM 'A',UNLESSA FORM'K HAS BEEN FILED DATA 'OCESSING COPY