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�v♦ wYl...♦..� n STATE OF CALIFORNII WATER RESOURCES CONTRO' -OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION (az TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: —Y ' FARM TANK-YES❑ NO (a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN–SO SPECIFY (A� A. OWNERS TANK ID# / B. MANUFACTURED BY: C. YEAR INSTALLED ( 7 Y D. TANK CAPACITY IN GALLONS: /0- II. TANK C.ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. A. 1 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 D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /, HAZARDOUS SUBSTANCE STORED 8 C.A.S.# ,r C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOKA,B,C,a D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑2 STAINLEssML ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANKF-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810DK METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 Allp LINING ❑3 EPDXY UNING ❑4 PHENOUC LINING LINING ❑ 5 GLASS LINING UNLINED F]95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IWA METHANOL? ❑YES ❑ NO ®'9'OTHER tJif) D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASSREINFORCEDPLA.STIC PROTECTION ❑ 5 CATHODIC PROTECTION EDWlDNE ❑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 ;m PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 U 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A LIPI15 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRI MARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(yo/r) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E:] NO THIS FORM HAS BEEN 6OMPLETED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# / L51 G CURRENT LOCAL AGENC FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE � 11 PERMIT NUMBER PERMIT APPROVAL DATE P MIT XPIRATION CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B S 29-88) THIS FORM MUST BE ACCOMPANI&TY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A LORRENT FORMA' HAS BEEN FILED ^ATA PROCESSING COPY