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STATE OF CALIFORNit WATER RESOURCES CONTROI ')ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IC MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ "PIAMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED ( - FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10 FARM TANK-YES❑ N43 N CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID# B. MANUFACTURED BYz A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 500 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM M IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. 011 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EKTERIOR UNER 95 UNKNOWN SYSTEM rj 2,pWLEWAU-ED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER Pi 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 OONCFEM ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑96 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED UNING F-]3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS UNING 0 6 UNUNm .KNOWN p ❑IS LINING MATERIAL COMPATIBLE WITH 100% ANOL? ❑YES [:]NO 99 OTHER �� D.CORROSION ❑1 POLYEFHLENEWRAP ❑ OR ASPHALT F-13 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASDC PROTECTION ❑5 CATHODICPROTECDON 91 NONE ,❑%UNKNOWN ❑%OTHER IV. PIPING INFORMAT 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 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 U 1STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 10 METHANOL COMPATIBLE FRP A U 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. -7 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS N P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,ESTI TED DATE LAST USED(MO/YR) 2. ESTIMATEDIOUANTITY OFGALLONS 3.WAS ANED K FILLWITH SUBST N MAINING IN IN ATERIAL? ❑YES ❑ NO THI§FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KA EDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® I ddI I 1010 lo CURRENT OCAL AGENCY FACILITY ID# APPAOV D NAM PHONE#WITH AREA CODE eajEw r7 PERMIT NUMBER �Sj.J�/ry•( PERMIT APPROVAL DATE PERMIT EXPIRA ION DATE CHECK. PERMIT AMOUNT SURCHARGEAMT.., TEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEITSY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A-CURRENT FORMA HAS BEEN FILED