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STATE OF CALIFORNI/' WATER RESOURCES CONTRO' 70ARD FORM 'B': UNDERGROUND STORAGE TANK PRO"uRAM ' TANK TANK PERMIT APPLICATION INFORMATION m b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED ffiz FACILITY/SITE NAME WHERE TANK IS INSTALLED: / U FARM TANK-YES❑ NO ❑ •Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDX B. MANUFACTURED BY: 11 C. YEARINSTALLEO 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. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED [213 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 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.X CA.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 1 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER D-IlSiTEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS 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 ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR 5 GLASS UNING6 UNLINED UNKNOWN LINING ❑ ❑ ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A IiJ 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 STEEL/IRON A U 2STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 5 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P ELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION X AGENCY X FACILITY ID X TANK ID X c I ooa = o CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED Y NAME ,/� PHONE S WITH AREA CODE C/ i �- a Vim!\/ PERMIT NUMBER PERMIT APPROVAL DATE P MITE PIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPTS BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIECS'V A FACILITY/SITE APPLICATION, FORM,X UNLESS =FORM HAS BEEN FILED r',ATA PROCESSING COPY