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STATE OF CALIFORNI, WATER RESOURCES CONTR<DOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ti- MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCL ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 0 TANK REMOVED '/� FACILITY/SITE NAME WHERE TANK IS INSTALLED: �j i� FARM TANK-YES M NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i© A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLEDNg Z D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. LIQ ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �FIODUCT ❑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 HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D A. TYPE OF ❑ I UBLE WALLED ❑3 SINGLE WALLED WITH EXTERK)R LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER E] 1 RU83ERUNED ❑2 DLINING ❑3 EPDXY LINING ❑4 PHENOLICUNING C. INTERIOR LINING F-15 GLASS UNING 6 UNLINED -] 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEDIANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP 2 TAA OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASSREINFORCEDPLAS'TIC 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 U PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEFUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATY LAST USED(MO/YR) 2. ESTIMATED DU NTITY OF 3.WAS TA K BILLED WITH SUBST C R NTNG IN GALLONS �%IN T ,EjIAI? E]YES ❑NO THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o I C) I o 3 CURRENT LOCAL AGENCY FACILITY IDN APPRO ED BY NA PHONE N WITH AREA CODE SrA2 5' PERMIT NUMBER PERMIT APPROVAL D T P MIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIM-5 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ALL", RENT FORMA HAS BEEN FILED DATA PROCESSING COPY