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r STATE OF CALIFORNII& WATER RESOURCES CONTR(WOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION I FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. O MARK ONLY ❑ 1 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 ❑8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: E. /Po FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY r A. OWNERS TANK ID# B. MANUFACTURED BY: UK C. YEAR INSTALLED X_ D. TANK CAPACITY IN GALLONS: lloo — II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL A. F-11 MOTOR VEHICLE FUEL F-12 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELMON ❑2 STAINLESS SFEEL ❑ 3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE Q 7 9LUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL %UNKNOWN ❑99 OTHER ❑ I RUBBER UNE] ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIORF-15 GLASS LINING ❑6 UNLINED UNKNOWN LINING F-1 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A 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 5 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 5 UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(95 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY Of INERT MATERIAL] OYES ❑ NO SUBSTANCE REMAINING IN "LLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY p JURISDICTION# AGENCY# FACILITY ID# TANK ID# �YF'C�TY IDM APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# eY: Ali FORM B(6-29-sa) THIS FORM MUST BE ACCOMPANIVWY A FACILITYPION, FORM 7N,UNLESS RRENT FORMA HAS BEEN FILED DATAPROCESSING