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i STATE OF CALIFORNI WATER RESOURCES CONTR BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION ob COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P RMANENTLYCLOSEDT ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 018-TANK REMOVED Q �J FACILITYYSITE NAME WHERE TANK IS INSTALLED: 6 7 L fi' FARM TANK-YES NO ❑ N F-� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID N I I B. MANUFACTURED BY: 14 14,6rCD C.YEAR INSTALLED u, K I D. TANK CAPACITY IN GALLONS: 60 II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL j ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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&CAS.# C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.6 D A.TYPE OF F-11 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AW INUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RIBBER UNE ❑2 ALM LINING ❑3 EPDXY LINING ❑ 4 PHENOUCUNING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNUNE !KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10010 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETMENE WRAP ❑ 2 TARORASPHALT ❑3 VINs RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, 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 fV296 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&M 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL Y05 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 P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS AM[�/•{ P 3 6 PRECISION TESTING P S ] PRESSURE TE STING P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERM ANEN 6YCLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? [_-]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY k FACILITY ID k TANK ID k ® 1:1= I Od l I I 0 I 0 171 CURRENT LOCAL AGENCY FACILITY ID X APPROVE BY NAM ^ L(.f� PHONE k WITH AREA CODE / PERMIT NUM ER PERMIT APPROVAL DATE7 f I FARNUT EXPIRATION DATE CHECK• PEBMRAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-2969) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A!,UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY