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STATE OF CALIFORNIA WATER RESOURCES CONTROL LARD FORM `B': UNDER-OROUND STORAGE TANK PROGI*AM ` TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 0 MARK ONLY ❑ 1 NEWPERMIT F] 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED ul FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4�h A. OWNERS TANK ID# d B. MANUFACTURED BY: CD C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,92NIPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM 0,BE it D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#' III. TANK CONSTRUCTION MARK ONE IAM ONLY IN BOX A,B,C,BD A.TYPE OF E];DOIJBUEWAUED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Zr2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERML ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑AR OTHER ❑ 1 RUBBER UNED ❑2 Ao LINING ❑3 EPDXY LINING ❑4 PHENOUCUNING C.INTERIOR 5 GLASS LINING UNLINED ❑95 NKNOWN LINING ❑ ❑ IS LINIMi MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO99 0THER D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC YJ PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFOR! N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B CONSTRUCTION An,/, SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE Cl MATERIAL ALUMINUM A U6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 O0 METHANOL COMPATIBLE FRP GALVANIZED STEEL A U 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. 1 VISUAL CHECK P S 21NVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS {vim P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMA ED O IA4 INN OF 3.WA ANK FILLED WITH SUS E REMAINING IN IN T ATERIAL7 YES ❑ NO GALLONS THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(MINTED&SIGNATURE? DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AOE!Y FACILITY ID# APPROVED BY NAME _ PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION dATE CHECK# PERMIT AMOUNT SURCHA®GE ANT, FEE CODE RECEIPT# BY: FORM B F 29.88) THIS FORM MUST BE ACCOMPANIEt A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A t,:,,RENT FORMA' HAS BEEN FILED