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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM 1 TANK TANK PERMIT APPLICATION INFORMATION w COMP,ETE A StPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PFRMANENTLYC NK ) ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2.00 • $ FARM TANK-YES NO O)_ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Im A. OWNERS TANK IO# d B. MANUFACTURED BY: T4*- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. w A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. / C. ❑ 1 UNLEADED E] 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT ®4 CJ OIL PRODUCT ❑4 GASAHOL ❑�5 JET FUEL ❑ 6 AVIATION GAS [-] 5 HAZARDOUS [-] 80 EMPTY [:] 95 UNKNOWN F-] 2 WASTE ❑ 7 METHANOL I g OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# IV C.A.S.#: .Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF OCJ ' DOUBLEWALLED ❑ 3 SINGLE WALLED WITH DRERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC, B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL' ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS UNINC P6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHUENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP Lof°FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A\,Uj 1 SUCTION A U 2 PRESSURE AL U 3 GRAVITY - A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINE'LI TRENCH (1 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A /p9 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL GLAD W/FRP I A V B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN Q A 99 OTHER V �1F LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ^ 1 P 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Oy[_7 P S- PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE S 95 UNKNOWN P 8 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEDDAE LAST USED(MO/YR) 2. ESTIMATED ftkkNTITY OF 3. WAP TANK FILLED WITH SUBST AINING IN i Irl MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF FIlERJURY,AND TO THE BEST OF MY KNOIAtEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0 jUO 10 CURRENT LOCAL,AGENCY FACILITY IO# APP OVED BY NAM _/ PHONE#WITH AREA CODE jPfERAlTBER PERT P VAL 0 TE PERMIT EXPIRATI N DATE PERMIT AMOUNT SURCHAR E T. FEE CODE RE�91PT# BY: FORMB(3-7-&e) THIS FORM MUST BE ACCOMPANIED Yll FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CU NT FORMA' HASBEENFILED DATA PROCESSING COPY