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.o r ,r STATE OF CALIFORNIA WATER RESOURCES CONTROL LARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 MARK ONLY F-] I NEW PERMIT F-13 RENEWAL PERMIT EY5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑S TANK REMOVED b t CA) FACILFTY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-YES❑ NO GJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFYLO D A. OWNERS TANK ID A B. MANUFACTURED BY: W C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.11),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 ❑3 CHEMICAL PRODUCT ❑A OIL ❑1 PRODUCT ❑1 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.R CAS.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C.&D A TYPE OF ❑ 1 DOUBLE W'U ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL B. TANK F-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOLCOMPARBLEFRP ❑ ❑ 9 BRONZE ❑10 GALVAMZBI STEEL ❑95 UNIQIONN 99 OTHER C. INTERIOR ❑ 1 RIBBERLINED ❑2 ALKYD LINING ❑3 EPDXY UNING 1 PHENOUCUNING LINING ❑5 GLASS LINING ❑6 LNJNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHEWWRAP ❑2 TAR OR ASPHALT ❑3WNYLWRAP ❑K 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 U I 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 I 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 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP 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. / • S 1 VISUALCHECK • 5 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P t 1 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Gi P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P t 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OFOALLONt 3.WAS TANK FILLED WITH 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 A SIGNATURE) ppTE LOCAL AGENCY USE ONLY COUNTY! JURISDICTION k AGENCY k FACILITY ID M TANK ID p CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE 0 WITH AREA CODE So PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK P PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: '(2-11skv FORM B(e-29-Be) THIS FORM MUST BE ACCOMPANIED m A FACILITY/SITE APPLICATION, FORM 'A'.UNLESS A CURRENT FORM'A' HAS BEEN RUED