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STATE OF CALIFORA I WATER RESOURCES CONTE.-,,BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F71 NEW PERMIT 713 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,,j FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: (.2 C. YEAR INSTALLED L(� / D. TANK CAPACITY IN GALLONS: p� 11. TANK C TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. MOTOR VEHICLE FUE A ❑ 3 CHEMICAL PRODUCTL ❑❑ 4 POETROLEUM B PRODUCT C E] 4 GNASAHOLD ❑ 5 JET FUEEL ❑ 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.R C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A.TYPE OF ❑ I DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER95 UNKNOWN SYSTEM ❑ 2 SNGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELPRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE E] 7 ALU MATERIAL INUM ❑B 100%METMANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL rDlOrUNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNLINEDUNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. 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 AJU>5 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 NONE A4_UJ05 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURETESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST SED( 0/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 6. GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ NO , G( THIS FORM HA BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION AGENCY# FACILITY IDN TANKID# E 1016 1 daoIllj 66S CURRENT LOCAI.AqIENCY FACILITY ID# APPROVED BY NAME iJ.,.QPHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT Y BY: • FORM B(6-29-B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'W HAS BEEN FILED DATA PROCESSING COPY