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STATE OF CALIFORN' WATER RESOURCES CONTR." BOARD ' FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION N 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 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8-TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a ' cyl FARM TANK-YES NO ❑ m I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY p A OWNERS TANK ID# -� B. MANUFACTURED BY: TI C. YEAR INSTALLED LI D. TANK CAPACITY IN GALLONS II. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. � C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ I OIL mDUOT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FU ,ENTER NAME OF HAZARDOUS SUBSTANCE ST ED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOX A.B,C.8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED MTH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SNGLEWALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 MORON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 LYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 VANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD ING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHAN ? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑1 POLYEfHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U I NDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE 4 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 ANV 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINVL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A I EEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 THER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDAY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P8 4 ECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P B 95 KNOWN P 8 99 OTHER 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 INERT MATERIAL? [--]YES ❑ NO DALL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILRY ID# APPROVED BY NAME ( PHONE#WITH AREA CODE 01) a T19 PERMIT NUMBER PERMIT APPROVAL DATE If PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIMB-Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS PISRRENT FORM'A' HAS BEEN FILED :IATA PROCESSING COPY