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STATE OF CALIFORNIA WATER RESOURCES CONTROI "OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM o: , TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLNKONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY o A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q� II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. }a A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL � PR0 UCT ❑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&C.A.S.# C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE TEM ONLY IN BOX A,B.C,A D A.TYPE OF ❑ I UBLE WALLED E] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EUK�STEEUIRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑ 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE MATERIAL ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B IW%METHANOL COMPATIBLE FRP i ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 DLINING ❑3 EPDXY LINING El4 PHENOLIC UNI NG LINING ❑5 GLASS LINING rLT6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEHMOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A UPI 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 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6 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. �C I P8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS .IF J�q1 P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST SED(MO/YR) 2. ESTIMATED OU TI OF 3. WAS TANK ILLED WITH SUBSTANC R A I AL?IN IN A I GALLONS E]YES ❑ NO THIS FORAlHASBkN COMPLETED UNDER PENALTY OF PER,&Y,AND TO THE BEST OF MY KNOWLEDbE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE II LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY {ID# -'7 TANK ID# CURRENT LOCAL AGENCY FACILITY ID# AP R VE BY AME PHONE#WITH AREA CODE CAr PERMIT NUMBER 3 PERMIT APPROVAL DATI! MRMMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCIORGE AMTO B aF'EE CODE - ECEIPT# BY: I i i FORMB(3-7-66) THIS FORM MUST BEACCOMPAIII.d BYAFACILFTY/SITE APPLICATION, FORM 'A',UNLESsw CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY