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STATE OF CALIFORN' WATER RESOURCES CONTR 30ARD FORM `B': UNDnGROUND STORAGE TANK PROOObRAM � .....4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ID FACILITY/SITE NAME WHERE TANK IS INSTALLED: W 5. 8 FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# O 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 02rl MOTOR VEHICLE FUEL 2 PETROLEUM C. 1 UNLEADED 2 LEADED 3 DIESEL00 F-1 3 CHEMICAL PRODUCT F-1 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑8 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 S C.A.S.N C.A.S.#: AA ,III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE [:] 7 ALUMINUM 8180%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVAN12m STEEL95 UNKNOWN 99 OTHER C. INTERIOR F-1 1 RUBIIERUNED ❑2 ALKYDUNING ❑3 EPDXY LINING 4 P NOCK LINING LINING ❑5 GLASS LINING Ej 6 UNLINED U,4t UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IDD%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHENEWRAP 2TAR OR ASPHALT [ 3V WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION E]91 NONE UNKNOWN 99 OTHER IV. PIPING INFORM% ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE Lw 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 1 OC%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(9 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. 1P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I• _. P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER •4/VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATIE LAST USED MO/YR) 2. ESTIMATED O ITY OF 3.WAST NK ILLED WITH SUBST% IN 1 RIALS YES ❑ NO GALLONS THIS FLJRM H S 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# E I D dZI -Z, DDS 1 CURRENT LOCAL AGENCY FACILITY ID# APP OVE B NAME PHONE#WITH AREA CODE S w loto it PERMIT NUMBER PERMIT APPROVAL BATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED \ \ DATA PROCESSING COPY