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STATE OF CALIFORNIA WATER RESOURCES CONTROIARD FORM 'B': UNDEkdROUND STORAGE TANK PRO AM = � � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY jf A. OWNERS TANK ID# O 1 B. MANUFACTURED BY: O' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E�j1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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&CAS,# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF ❑ SYSTEM 14 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-1I RUBBER LINED E] 2 ALKYD LINING F--] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F-15 GLASS LINING �NLINED ❑95 NOWN 1 � ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 To OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION yv 1 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 C.MATERIAL A U 5ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A 9 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. /VW P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS FPS 6 PRECISION TE STING P 8 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM TED DATE LAST USED(MO/YR) 2 ESTIMAT QUANTITY OF 3. W S TANK FILLED WITH SUB REMAINING IN E T MATERIAL' ❑YES ❑ NO GALLONS THlh FORM HAS BEEN COMPLETED UNDER PENALTY 6F PERJURY,AND TO THE BEST OF MY KN &LEDGE IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# d / z31 G b lo CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE c�CF.r� -P 3rd PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIAATIOII DATf CHECK# PERMIT AMOUNT SURCHARGE AMT.y FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIlV*A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ArdIiRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY