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STATE OF CALIFORNr) WATER RESOURCES CONTR( 30ARD 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 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE E TANK REMOVED /C96— FACILITY/SITE NAME WHERE TANK IS INSTALLED: /_�Z 75_ FARM TANK - YES ❑ NO ❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN —SOS IFY A. OWNERS TANK ID X B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF (A7), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A Erl MOTOR POETROLEUM BIL C ❑ 3 CHEMICAL PRODUCT 4 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 HAZARDOUS SUBSTANCE STORED & C.A.S. R C.A.S. W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOIL A,11 C, &6 A. TYPE OF ❑ I DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINERNKNOWN A SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U UNKNOWN ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALU M E]6100% METHANOL COMPATIBLE FRP MATERIAL [j 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER A F-]1 RUBBED LINED ❑ 2 AM LINING ❑ 3 EPDXY LINING ❑ 4 PH LINING C. INTERIOR LINING ❑ 5 GUSSUNING ❑ 6 UNLINED A UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYEIHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 W ❑ 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 NON A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM ONCRETE A U 7STEELCLADW/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEE AA� U "j �'NKNOWN 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 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P OSE LLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NON P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY Of 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS THUS AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY ?RECT. COUNTY R JURISDICTION R AGENCY k FACILITY IDS TANK ID k / CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE « W TTX AREA CODE I PERMIT NUMBER I PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT I SURCHARGE ANY. I FEE CODE REFEIPT R I S "OHM R r6 -29 -eat THIS FORM MUST BE ACCOMPANIED Y A FACILITWSITE APPLICATION. FORM 'A'. UNLESS URRENT FORM'A' HAS BEEN DATA PROCESSING COPY