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STATE OF CALIFORNIO WATER RESOURCESCONTROI -OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION 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 F-12 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �BaANIVREMOVED 0'q GXf FACILITY/SITE NAME WHERE TANK IS INSTALLED: a 1 ,I, FARM TANK-YES❑ NO M I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4�b A. OWNERS TANK ID# ©a- B. MANUFACTURED BY: C. YEARINSTALLED D. TANK CAPACITY IN GALLONS'. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. * EE1'IMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Rt 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. 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 ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE E]10 GALVANIZED STEEL KNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING F-1 4 P'H',ENNOOUC�UNING C.INTERIOR IN NG R ❑5 GLASSUNING ❑6 UNLINED �,,,D46- ry WN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ N0 - D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYEWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE _CDOWN ❑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 <;(-,nKNOWN 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 U 95 NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM ACONCRETE A U 7STEELCLADW/FRP A U 810D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 9 UNKNOWN A W,99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P S I GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P - 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# M I O O � h a cr I I O I In Io CURRENT LOCAL AGENCY FACILITY ID k /,U S� I I APPROVED BY NAME -I ILNONE N WITH AREA CODE PERMIT NUMBER ll PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNTI SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(D-29-RE) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLES RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY `�