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STATE OF CALIFORNI! WATER RESOURCES CONTRC `,OARD FORM 'B': UNDERGROUND STORAGE TANK PROMRAM (% Z TANK TANK PERMIT APPLICATION INFORMATION COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IG MARK ONLY Efri NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION [:j 7 PERMANENTLY CLO ED TAN ONE ITEM F--] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED�O FACILITY/SITE NAME WHERE TANK IS INSTALLED: G �(/• 1-1 FARM TANK-YES❑ NO .p I. TANK DESCRIPTION COMPLETE ALL /ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# I B. MANUFACTURED BY: C. YEARINSTALLED I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P EUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT L401L ❑ 1 P UCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL THER(DESCRIBE IN ITEM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF or HAZARDOUS SUBSTANCE STORED 8 C.A.S.# 1,21,1 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DOMLE WALLED ❑3 SINGLE WALLED WITH EKTBiIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL 3 RBERGLASS ❑4 STEEL CLADW/RBERGLA85REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED [—]2 ALI(YD L ❑3 EPDXY UNING ❑4 PHENOLIC UNING C. INTERIOR 5GLASS LINING UNE0 ❑%UNKNOWN LINING ❑ ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAROK PHALT F-13 VINYL WRAP E)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 U 2 PRESSURE A GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONEUNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA U CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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. 6ffIPl VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PRECISION TE STING P 5 ] PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/ ) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �.Ar/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E:]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY N FACILITY ID R TANK IO# En U 1 G I d D I cG C CURRENT LOCAL AOE CY ACILITY`IDN APPROVED BY AM PHONE#WITH AREA CODE PERMIT NUMBER (,(•�1, PERMIT APPROVAL AT P MITE IRATION DAVE CMECKN PERMIT AMOUNT SURCHARGE MT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY