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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION }� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z i0 MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PE MANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED d N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID# , 8. MANUFACTURED BY: Aloe— CO C. YEARINSTALLED C D. TANK CAPACITY IN GALLONS: C1 II. TANK NTENTS 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 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SI WALLED ❑4 SECONDANYCONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRO ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL El CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ K,UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE WITH METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR ALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROU U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 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 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A,,IU 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A Nj STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U WSOTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECOND ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 WELLS P8 4 CTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S ] PRESSURE TESTING 9 91 NON P S 95 UN OWN P B 99 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 OALLONB INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN 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# = = = 10101--5-1311& 111101001f CURREN OCAL AGENCY FACIVTY IDN APPR_QVJED BY NAME 4Y/1 PHONE N WITH AREA CODE PERMIT NUMBER SoJ PERMIT APPROVAL DAT PERMIT EXPIIRA— TION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT R BY: V� FORMS(5-29-B6) THIS FORM MUST BE ACCOMPANIEC19Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A G.:ARENT FORMA HAS BEEN FILED DATA PROCESS