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,-. -rv- STATE OF CALIFORNIA WATER RESOURCES CONTROL E RD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMR ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS O In ONE ITEM F12INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED ((// Lrl FARM TANK-YES NO ❑J�44 -7 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C" '1 B. MANUFACTURED BY: A. OWNERS TANK ID# �` C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. ,11 A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM C. ❑1 UNLEADED LEADED ❑3 DIESEL 11 ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 6 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EITERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SIEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W)FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALU M ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑W OTHER ❑ 1 RIBBERUNED ❑2ILMUNING ❑3 EPDXY LINING ❑4 PHENOLICUNING C. INTERIOR ❑5 GLASS UNING ❑6 UMINED UNKNOWN LINING ❑IS LINING MATERIAL COMPATIBLEWITH 100%MEIHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 11>5 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. .,. �' O P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 SE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS v n"� P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FII WITH SUBSTANCE REMAINING IN GALLOI/B 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# JURISDICTION# AGENCY# FAC! B� TANK ID# m � � oo zce 600 El— CURRENT LOCAL AGENCYpFACILITY 10 p APPROVED BY NAME L�/� PHONE#WITH AREA CODE W—, PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT# BY: FORM a(6-29-36) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY