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STATE OF CALIFORNIb WATER RESOURCES CONTRCOARD 5 °' FORM `B': UNDERGROUND STORAGE TANK PRO AM �a TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `;,,o '' Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C OS NK ONE:ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S { FARM TANK-YES❑ NOFWN N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIE A. OWNERS TANK ID U B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICALPRODUCT ❑ 4 OIL ❑ 1 ODLJCT ❑ 4 GASAHOL FUEL E]6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY [:] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL r99OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �/ HAZARDOUS SUBSTANCE STORED&C.A.S.H (J!`Tjf C.A.S.ff: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOJ(A,B,C.&D A.TYPE OF ❑ 1 D LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 51 LE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CI-AO WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 16 GALVANIZEOSTEEL ® 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. LINING R ❑ 5 GLASS LINING ❑ 6 UNLCNEO ❑ IS LINING MATERIAL COMPATIBLE WITH 1pM%METHANOL? ❑YES ❑ NOP4NKNOWN 9 OTHER D. CORROSION ❑ 1 POLYEfHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AlU I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A LL.6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADflSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELtS I`flV1l P 5 6 PREC9SIONTESTING P 5 f PRESSURETESTING P 5 91 NONE P 5 95 l7NKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. EST9MATED DAT£LAST USED(MOlYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLE�VWIITH SUBSTANCE REMAINING IN VERT MATERIAL ❑YE5 ❑ NO �� THis FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# /} FACILITY ID�# TANK ID# F7 I I I ol V CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE Vk WITH AREA CODE p PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY. it FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A`,UNLESS A CURRENT FORMA' HAS BEENFILED DATA PROCESSING COPY