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STATE OF CALIFORNIA WATER RESOURCES CONTRf- BOARD FORM 'B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION (oz COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. to MARK ONLY ❑ 1.NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA K ONE ITEM �2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED:,jn/ Lti/ FARM TANK-YES❑ NO ET Ib► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: r�0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A_ [L�1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 62r2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL riPRODUCT ❑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 8 0A.# C.A.S.#. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑��-7,,1,DOUBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN U SYSTEM b`SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING KI/6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WRH IDA METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A PRESBURE 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 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM AU fiCONCRETE A U 7STEEL CLAD W/FRP A U 81017%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 5 UNKNOWN A U 99 OTHER �/. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 6 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS S P S PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMAT D QUANTITY OF 1 3.Wff TANK FILLED WITH N1 A SUB T REMAINING IN_ [—]GALLONS I Al ATERIAL7 YES ❑ NO THIS FORM AAS BEEN COMPLETED UNDER PENALTY dF PERJURY,AND TO THE BEST OF MY KNO EDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY C UNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURB NT LOCAL AGENCY FACILITY ID# APPROVED BY NAM PHONE#WITH AREA CODE PERMIT NUMBER PERMITAPPROVAL DATE PE MIT EX RIATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', A CURRENT FORM'R HAS BEEN FILED j DATA PROCESSING COPY