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STATE OF CALIFORNIf WATER RESOURCES CONTRO' 'OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM '' TANK TANK PERMIT APPLICATION INFORMATION `g`m,ro' `° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 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 ❑B TANK REMOVED O'L FACILITY/SITE NAME WHERE TANK IS INSTALLED: () IF, K FARM TANK-YES❑ NO -y I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# 0' B. MANUFACTURED BY: C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: O,00 0 w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1I A kj I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. G ❑ I UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL K111PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑' 80 EMPTY ❑ 95 UNKN WN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DEEaCRIBE IN REMO OW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.4 C.A.S.W All. TANK CONSTRUCTION MARK ONE IT M ONLY IN BOX A,B,C.8 D A. TYPE OF ❑C3/2 y/'1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN 8 r SYSTEM "CSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEEUIRON I' ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CND WIFIBERGLASS REINFORCED PLASTIC ' B.TANK MATERIAL F--] 5 CONCREM T°} ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM [:] 8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑ 99 OTHER ,Z F-1I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LININGF-1 4 PHENOLIC UNI NG C. INTERIOR ! .y LINING ❑5 GLASS LINING ®'S UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCEDPUSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ®%UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE J A. SYSTEM TYPE A to 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A t0jl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVCI A U 4 FIBERGLASSPIPE C. MATERIAL A U S ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A P:95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S. 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 9f NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/VR) 2. ESTIMA D QUANTITY OF 3. WAS ANK FILLED WITH SU 5 C REMAINING IN GALLONS Ff ATERIAL7 ❑YES ❑ NO THIS F RM AS 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 COUrnNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# It CURRENT LOCAL AGENCY FACILITY ID# APP OVED BY NAME PHONE#WITH AREA CODE y ' PERMIT NUMBER P RMIT APPROVAL TE PERMIT EXPIRATION DATE z ��. IIIL CHECK♦ PERMIT AMOUNT - SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(37-RB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITEAPPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY