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STATE OF CALIFORNI! WATER RESOURCES CONTROI OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �' COMPLETE A SEPARATE FORM WITH THE FOLLOWING!YFORMATION FOR EACH TANK. - Z 0 MARK ONLY ❑ 1 NEW PERMIT r-13 RENEWALPERMIT E5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /S FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7Y FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A IV A. OWNERS TANK ID B. MANUFACTURED BY: M C YEAR INSTALLED y' D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,Co LETE 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&CAS.# vg--- V C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 IE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEELARON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.MATERIAL TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-] 1 RUBBER LINED ❑2 LINING F-13 EPDXY LINING E:] 4 PHENOLIC UNING C.INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN AIS/ ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO OTHERyn,` D. CORROSION ❑1 PoLYETHLENEWRAP ❑2 TARORASPHALT F-13 VINYL WRAP F] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION gll-'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 2 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 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 810D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ®95 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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 5 P 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST U JSD �) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BE N COMPLETED 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 R mI I I / EEE ZI I I / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N p PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXPIRATION DOVE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B I6-29-RR) THIS FORM MUST BE ACCOMPANIEtr=Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A. ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY