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STATE OF CALIFORNL WATER RESOURCES CONTRO RD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ ❑ ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK i O 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 S 6'; 2DL. FARM TANK-YES NO ❑ Ii I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY uu A OWNERS TANK ID# B. MANUFACTUREDBY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 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 ❑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 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRGN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS 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 ❑ I RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ----- -' ❑ IS LINING MATERIAL COMPATIBLE WITH 10016 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, 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 SINGLEWALLED A U 2 DOUBLEWALLED 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 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/FRPA U 8 100%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. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 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(NONE) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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# ET I I I -/I= 0 ED CURRENT LOCAL AGENCY�A�IL17:Y WSJ APPROVED BY NAME PHONE N WITH AREA CODE / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E PIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED