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STATE OF CALIFORN' WATER RESOURCES CONTP BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` sF;- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / I FARM TANK-YES ] NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IG A. OWNERS TANK ID# / B. MANUFACTURED BY: (cam C. YEAR INSTALLED MY 0, TANK CAPACITY IN GALLONS: U W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED 2 LEADED ❑ 3 DIESEL A ❑3 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.#: MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM g21SINGLE WADED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS BTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK -1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑!11 LKYD UNING F-13 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR LINING ❑5 GLASS LINING L06 UNLINED ❑ 95 UNKNOWN ❑B UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 PLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCEDPLASMC PROTECTION5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A .0 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A 0095 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 0 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 S I VISUAL CHECK OS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH A SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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# JURISDICTION N AGENCY N FACILITY ID M TANK ID# = = 06 I D 7 16010 1 /1 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE G ga9gcT - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY/STE APPLICATION, FORM 'A',UNLESS A NT FORMA' NAS BEEN FRED DATA PROCESSING COPY