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STATE OF CALIFORNIA- WATER RESOURCES CONTR*OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 11 TANK MARK ONLY F-1i NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED TANK .❑'ffTFNK REMOVED ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE N D L (iY_lC5f� .1b. FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: l� .A I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 00 AN B. MANUFACTURED BY: . OWNERS TANK ID f� D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED 1 I. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),15 NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL A.�'�MOTOR VEHICLE FUEL ❑2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ fi AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D ECORROSION DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EBTEMOR LINER KNOWN ❑ ❑ gg OTHER ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP L ❑9 BRONZE ❑10 GALVANIZED STEEL ❑-9�UNKNOWN ❑99 OTHER❑1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING R ❑5 GLSS UNING ❑6 UNLINED KNOWN ( f❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO THERION ❑ I POLYETHLENEWRAP ❑2 TAAORASPHALT ❑3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTICTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �1_"NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAAPPUICA BNONE A U 5-UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESS STEEL 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 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(�U UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR PP S 559GRROU D WATER MONITORING WELLS OTHER P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING p $ 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW TE DGE,IS TRUE AND CORRECT . APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID N COUNTY N JURISDICTION N AGENCY N FACILITY ID N x03- 1 K= APPROVE By AA( �/ PHONE WITH AREA CODE CURRENT LOCAL AGENCY FACO�� 1,.�J\ c \o/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE _ PERMIT NUMBER SURCHARGE AMT. FEE CODE RECEIPT X BY: CHECKX PERMIT AMOUNT LESS A CURRENT FORMA' HAS BEEN FILED FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISI A APPLICATION, NGRCOP A',UN