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o STATE OF CALIFORNIA$ WATER RESOURCES CONTROWARa y` •°•" r"`s. FORM `B': UNDERGROUND STORAGE TANK PROGRAM �T TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ""-`°'" z 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED 0/ " FACILITY/SITE NAME WHERE TANK IS INSTALLED- FARM TANK-YES❑ NO 4b- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# � B. MANUFACTURED BY: G.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(Ai),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I� MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ®-r PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 86 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&C.A.S.# C'A'S'#' Z�zd 111. TANK CONSTRUCTION MARK ANE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTEMOR LINER ❑ 95 UNKNOWN SYSTEM 2'SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE V95 UMINUM F-18 100%METHANOL COMPATIBLE FRP MATERIAL F-19 BRONZE ❑ 10 GALVANIZED STEELNKNOWN ❑ 99 OTHER F-11 RUBBER LINED F-]2 D LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING LJ I-1 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ ISLINING MATE91AL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATJQN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 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 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100911 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. PS VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADQSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNC WATER MONITORING WELLS f R S PRECISION TESTING P 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 D TE LAST USED(Md1YR} E:�IMATED OUANT� OF 3.WAS TANK LLEC WITH STANCE A IN IN INERT M L? YES ❑ NQ a GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) PATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# OTT 61 C1 CURRENT LOCAL AGENCY FACILITY ID M APPR V D,BY NA PHONE M WITH AREA CODE LPERMITNUMBERPERMIT APP L DAT P RMIT XPIRATION DATE M PERMIT AMOUNT SURCHAR E AMTJ FEE CODE ECEIPT M BY: FORM R(6-29-8B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A`,UNLESS A CURRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY