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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7PERMANENTLY CLOqEDTANK ONE ITEM ❑ 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY u IG A. OWNERS TANK ID k # B. MANUFACTURED BY: C. YEAR INSTALL D. TANK CAPACITY IN GALLONS: W II. TANK C99iTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS N T MARKED,COMPLETE ITEM D. CG A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT F-1B,4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 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.W C.A.S.R: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM EZ2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 INUM ❑B 1DD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH IC UNING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES PNO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U t SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 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 C. MATERIAL A U 5ALUMINUM A U CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 t VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN OMPLETED 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 B JURISDICTION# AGENCY k FACILITY ID R TANK ID# CURRENT j OENCY FAQILITY IDM APPROVED BY NAME �� PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE IT EfPIRATION DAIFE CHECK PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTF BY: II ^ FORM B(3-7-88) THIS FORM MUST BE ACCO MY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATORRENT FORMA' HAS BEEN FILED \J' DATA PROCESSING COPY