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STATE OF CALIFORNIf WATER RESOURCES CONTRO' ZOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM f 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Ew FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 dQ 3 e>^ Lrl FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 5O A. OWNERS TANK IDB. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. c" A. 1 MOTOR VEHICLE FUEL [-] 2 PETROLEUM B. G [:] 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �1 PRODUCT E] 4 GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS E]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.W .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM F 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING F]4 PHENOLIC LINING LINING C. OR ❑5 GLASS LINING ❑6 UNLINED UNKNOWN LININ ❑ ISUNING MATERMLCOMPATELEWRH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. T AR OR PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 I rINONE ASPHALT UNKNOWN REINFORCED PLASTIC NOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A&I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 095 UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE Inc) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1995 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. Pt S P S I VISUAL CHECK S I PRECISION TESTING09 2 S 7 PRESSURETEST RECONCILIATION P B 3 VNONEEWELLS P s 95E ECTRONIC OWN MONITOR P S 55 GROU99 ND WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ) ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED OUANTITY OF 3, WAS TANK GALLONS FILLED WITH A SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO /v THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10 1oola1: CURRENT LOCAL AGENCY FAGILIT'ID# APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE `v111II CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3�7- ) THIS FORM MUST BE ACCOMPANI r A FACILITY/SITE APPLICATION, FORM'A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY