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STATE OF CALIFORNIA ,- WATER RESOURCES CONTROL F- lRD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ` = TANK PERMIT APPLICATION INFORMATION ' ' TANK COMPLW A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNO -SO SPECIFY �I A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC, L�J<UNLEADED ❑ 2 LEADED E] 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL B. 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ SO 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.N C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGIEWALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 BNGLEWAUED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑ 3 RBERGIASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 1 ALU ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GAIVANiZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GM UNING ❑6 UNUNED ❑.IFDII ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:]NO OTHER C D. CORROSION ❑ I POLYETHIENE WRAP ❑2 TAR OR ASPHALT ❑3 VI AP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE TPVC) A U 4 FIBERGLASS PIPE 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(995 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 S1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS h P S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER ✓VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U ED TMO/YR) 2. ESTIMATED QUANTITY OFOALLON8 3.WAS TANK FILLED WITH IIS SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY N FACILITY ID k TANK ID N CURRENT LOCAL AOE FADILRY ID• APPROVED BY NAJE -PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PipomilT EYPIRATIO ATE CXECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: `\ FORM B(6 29 88) THIS FORM MUST BE ACCOMPANIE&%A*A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A._,ARENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY