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STATE OF CALIFORKS. _ WATER RESOURCES CONI BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. l MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7/PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE rg'13 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO LjN 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY -4 A. OWNERS TANK ID# ,./ B. MANUFACTURED BY: C/( C.YEAR INSTALLED IAK D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. E:11 UNLEADED 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT [—] 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑E EMPTY D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&0 A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER FiKUNKNOWN SYSTEM ❑2 BNGLEWALLED 4 SECONDARNCONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ f RUBBER UNE ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 RIENOUC LINING C. INTERIOR LINING ❑5 GIASSUNING ❑ 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPANBLEVITT H I Do%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLBIE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑5 CATHODIC PROTECDON ❑91 NONE r 5 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 AJUA UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE U UNKNOWN A U 99 OTHER A U i 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 ALUMINUMU 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOLOOMPATIBLEFRP A A U 9 GALVANIZEDSTEEL U 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S SE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TE STING P S ] PRESSURE TESTING S 91 P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOIYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLEDWITH 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. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# oC L CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY MAIIIE ^ PHONE#WITH AREA CODE !a PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXPIRATION DATE CHECK a PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ?oar.^E:6 P9.88, THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED