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STATE OF CALIFORNIA` WATER RESOURCES CONTRO' 'OARD FORM `B': UNDER73ROUND STORAGE TANK PROURAM TANK TANK PERMIT APPLICATION INFORMATION , ° CO ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY Rri NEW PERMIT [:]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O / I 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# K) B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONSp000: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. r A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. F04GASAHOL ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL RODUCT ❑5 JET FUEL ❑6 AVIATION GAS❑5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER( F)§CRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# CAS.#: MI. TANS( CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER .TANK ®'1 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑S POLYVINYLCHLORIDE 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FHP ❑9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOUC LINING LINING ❑ 5 GLASS LINING [1�11'51IDNED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE NTH 100%METHANOL? YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TA OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U MOTHER A STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. y1'' P S t VISUAL CHECK f 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND W TER MONITORING WELLS �`7 P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 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? E]YES [_—] NO 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 N TANK ID# l s z ov CURRENT LOCAL AGENCY FACILITY ID a AP q ED BY NAME PHONE N WITH AREA CODE CU; p� PERMIT NUMBER PERMIT APROV DA E PERMIT EXPIRATION DATE - k -77 CHECK N PERMIT AMOUNT SURCHAR EAMT. FEE CODE RECEIPTN BY: FORMS(3-7-BS) THIS FORM MUST BE ACCOMPANIED CM FACILITY/SITE APPLICATION, FORM `A',UNLESS A C rMNT FORM'A' HAS BEEN FILE DATA PROCESSING COPY