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STATE OF CALIFORNIA' WATER RESOURCES CONTROI -OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m� o TANK TANK PERMIT APPLICATION INFORMATION CO ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED TANK ONE ITEM ❑ ❑ 2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# NON t B. MANUFACTURED BY: U� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: jf��+ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. '1MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. EjKUNLEADED ❑2 LEADED ❑ 3 DIESEL ~ ❑3 CHEMICAL PRODUCT ❑4 OIL 52 1 pRODUCT ❑ 4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER TZRIBE IN ITW O,.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. TAN CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I OOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95UNKNOWN SYSTEM EJ�INGIEYIALtED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PUSTIC' B.TANK ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8100%METHMIOL COMPATIBLE FRP MATERIAL F-1 5 CONCRETE ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBERLINED ❑2 ALKYD LINING F-]3 EPDXY LINING E] 4 C.INTERIOR PHENOLIC LINING LINING ❑5 GLASS LINING ERI-UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER 0.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E jKWME ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A nl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A n STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A IT 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. L P 8 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS J P 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P(1)99 OTHER aA✓I,n/ 1/AY/lu (�p1I VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED GUANTITY OF &WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# v' �lI d O CUNPENT LOCAL AGENCY FACILITY IO# APP VEO BY NAM PHONE#WITH AREA CODE 7 g12 W PERMIT NUMBER P R TAPPROVA DAT4 I PERMIT EXPIRATION DATE ^+- s i2 g8 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B S-7-6&) THIS FORM MUST BE ACCOMPANIED VrA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 0904MT FORMA' HAS BEEN FILED OATA PROCESSING COPY