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STATE OF CALIFORNIA' WATER RESOURCES CONTRO' -OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM �� H TANK TANK PERMIT APPLICATION INFORMATION m COMP E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- Z :C MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED IiQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: "• FARM TANK-YES❑ NO j1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O ZVO II. TANK CO TENTS F(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO PLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑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 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED&C.A.S.9 C.A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ =W WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2SINGLE WALLED ❑4 SECONDARY CONTAINMENT F]99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEELFIBERGLASS ❑4 STEEL CUD W/FIBERGLSS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBERUNED ❑2 ALKY ❑3 EPDXY UNING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LININGNUNED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH t00%METHANOL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION NONE ❑95 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 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 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 A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIMP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6095 UNKNOWN A U99 OTHER V LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTIN S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i.ESTIMATED DATE LAST US /Y 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS B N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION# AGENCY N FACILITY ID k TANK ID M � =i o 0I CIO— CURRENT LOCAL AGENCY FACILITY APPROVED BT yAY�C/ ONEN WITH AREA CODE PERMIT NUMBER PERMIT/APP RMI DktE L ) �� ICHECK N PERMIT AMOUNT SURCHARGE A FEE CODE RECEIPT N BY: FORMR(6-29-ee) THIS FORM MUST BEACCOMPAN BYAFACILITY/SREAPPLICATION, FORM 'A',UNLESSA- URRENT FORMA' HASBEENFILED ---> DATA PROCESSING COPY