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STATE OF CALIFORNIA' WATER RESOURCESCONTRO' 'OARD FORM `B': UNDERGROUND STORAGE TANK PROMAM ` TANK PERMIT APPLICATION INFORMATION ° TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — Z 10 MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSEDT K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED U r W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES[—] NO W F1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID# B. MANUFACTURED BY: [� C. YEAR INSTALLED A K D. TANK CAPACIT'IN GALLONS' II. TANK C NTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO PLETE 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&C.A.S.# C.A.S.#. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A. TYPE OF ❑ 1 UBLE WALLED F—] 3 SINGLE WALLED WITH EKFERIOR LINER ❑95 UNKNOWN SYSTEM SINGLIEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER f STEEUIRON ❑2 Is STEEL ❑3 FIBERGLASS ❑4WEE CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED.STEFL - ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALM LINING ❑ 3 EPDXY UNING ❑ 4 HENOUC LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED 95 U MOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEfIiANOL? ❑YES ❑ NO ER u/'4 D. CORROSION E] I PROTECTION ❑ 5 CATHODIC PPROTECTION ❑ 2 IM 91 NONASPHALT ❑95VINYL WRAP 4 UNKNOWN ❑NFOTH BUSS REINFORCED FUSTIC IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 0 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 0 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AU 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 STEEL CLAD W/FRP A U B 100%METHANOLCOMPATISLEFRP A U 9 GALVANIZED STEEL A U 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. 46 P VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S1 PRECISION TESTING4>' 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 IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH NA GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# C Ij7 f00 CURRENT AGENCY A ILITY IDA APPROVED Y M PH ONE N WITH AREA CODE a PERMIT NUMBER PERMIT APPROVAL D" PERMIT EXPIRATION DA ,96111 '7 CHIPERMIT AMOUNT SURCHARGE MT. FEE CODE RE EIPTN BC FORM a Is-z9-eal THIS FORM MUST BE ACCOMPANIEDw A FACILITY/SITE APPLICATION, FORM `A`,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY