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STATE OF CALIFORNI WATER RESOURCESCONTRY IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OFINFORMATION❑ 7 P MANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 EMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: G(i FARM TANK -YES Z NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A II. TANK CONTENTS IF [A.1), IS MARKED. COMPLETE ITEM C. IF (A.1 1. IS NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 5 HAZARDOUS ❑ 80 EMPTY Zf95 UNKNOWN B. ❑ i PRODUCT ❑ 2 WASTE C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, HAZARDOUS SUBSTANCE STORED ENTER NAME OF & C.A.S. R ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT GAS. M: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, S D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH DaERIOR LINER95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 MEL CLAD W/RBERGIASS REINFORCED PLASTIC TANK B. MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑95 MINUM ❑ 8100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL I �-�1 UNKNOWN ❑ 99 OTHER ❑ 1 RIJ88ERUNED ❑ 2 ALKYDUNING ❑ 3 EPOKYUNING ❑ OLIC UNING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNUNED 95 NKNOWN),�Ap" ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES❑ NO OTHER ✓"'-�' D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 21,95 UNKNOWN ❑ 99 OTHER W. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 0 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 ERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A^ 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. v S t VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIM4TED DATE LAST USED (MO/YR) 2. ESTIM71ED QUANTITY OF I R WAR T&NX Pu I Fn WIT. Vl" FORM HAS BEEN COMPLETED UNDER PENAL APPLICANTS NAME (PRINTED & SIGNATURE) Aur NUT U51: :E REMAINING INTERIAL? —]YES NO GALLONS PERJURY, AND TO THE BEST OF MY KNOWL DGE, IS TRUE AND CORRECT. DATE COUNTY M JURISDICTION R AGENCY R FACILITY ID # TANK ID R b l 1 C' (9 lo 17 CURREUILOCAL A� FACJLITYJD� AP7 ��Y NAME �^ PHONE M WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE ORM B S -29-m) THIS FORM MUST BE ACCOMPANIED151 A FACILITY/SITE APPLICATION. FORM 'A'. UNLESS DATA PROCESSING COPY RECEIPT# I BY: FORM'A' HAS RFFN FII Fn m