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STATE OF CALIFORNI! WATER RESOURCESCONTRO'� OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ,mom TANK TANK PERMIT APPLICATION INFORMATION CO ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 1 O MARK ONLY Ff 1 NEW PERMIT ❑3 RENEWAL PERMIT ;J �CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED {A/I ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A W A. OWNERS TA NK ID# B. MANUFACTURED BY: C. YEAR INSTALLED /97V D. TANK CAPACITY IN GALLONS .3 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL [ 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,AD A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ffjklNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER EL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS 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 F--] I RUBBERUNED E]2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOUC UNING LINING ❑ 5 GLASS UNING � UNLINED 95 UNKNOWN / ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER Un K 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2T RASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 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 UNED TRENCH A U 91 NONE A CP95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P A 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER VI. 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 - NGALLONS INERT MATERIAL? [-]YES ❑ NO THIS FORM HAS 8 EN COMPLETED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 00 CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 4RMIT XPIRATION COft t ,` CHECK# PERMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# UBY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEWf A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY