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STATE OF CALIFORNk; WATER RESOURCES CONTR�.IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM .. •.. TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. �" Z 10 MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT N6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED (A� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK•YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY C� A. OWNERS TANK IDp B. MANUFACTURED BY: UIL C. YEAR INSTALLED )L- I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMP ETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUV95 B. C. ❑ 1 UNLEADED ❑2 LEADED E:] 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL F-1i PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS [-]5 HAZARDOUS ❑ 80 EMPTYKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 RBER ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POUNNYLCHLORIDE ❑ 7 MINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL M UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 P LIC LINING C.INTERIOR LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑UW M P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 GATHODICPROTECTTON ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A &95 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 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER Kl- VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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&SIGNATURE) DATE LOCAL AGENCY USE ONLY C`ORU�NTY/# JURISDICTION# AGENCY# FACILITY ID# TANK 10# 7`LJ—LJ CURRENT LOCAL AGENCY F ACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ( CHPERMIT AMOUNT SURCHARGE AMT. FEE CODEI� RECEIPT N BY'./v. mm ,\7`IN-11 FORM B(6-29-88) THIS FORM MUST BE ACCOEDlrA FACILRY/SRE APPLICATION, FORM 'A',UNb woo FOM RENT RA' HAS BEEN FI7LEED DATA PROCESSING COPY