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STATE OF CALIFORN# WATER RESOURCES CONTBOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM v ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. rr] MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLp5URE 8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: i pile .v. & S..L I /� FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN KNOWN-SO SPECIFY r+h A. OWNERS TANK ID# ! B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS 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. ❑ 1 UNLEADED ❑2 LEADED3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS N ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 0 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.ff �j-j3. C.A.S.q: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOJ(A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK El STEELPRON ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD WFIBERGI.hSS REINFORCED PLASTIC ❑5 CONCRETE 0 6 POLYVINYLCHLORIDE ❑ MATERIAL �J ❑ 7 ALUMINUM 6 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINER 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED EK UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MFTHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ i POLYEIHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTH€R. IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A W1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 07HER A U 1 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AJu)95 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 3 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH WA SUBSTANCE REMAINING IN INERT MATERIAL?ATERIAL? ❑YES ❑ Np THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGF, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# T/ANK ID# CURRENT LOCAL AGENCY FA5LLITY IDS APPROVED B NAME ` (, PHONE#WITH AREA CODE LPERMITNUMISER' � PERMIT APPROVAL DAT PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# 8Y: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEu Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY