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STATE OF CALIFOR1416 WATER RESOURCES CONTRWOARD ? FORM 'B': UNDERGROUND STORAGE TANK PR RAM ,f TANKTANK PERMIT APPLICATION INFORMATION NK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TA 1 C) MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO .A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY y O A. OWNERS TANK IDB. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: J D O 11. TANK 92NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM �R. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL LJ/, PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8,C.A.S.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ffe SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Z, STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN NG IS LINING MATERIAL COMPATIBLE WITH IM%METHANOL7 YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 V LWRAP ❑ 4 FlBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 95 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 P2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 9/ NONE AM 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLOROE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A m 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 Q S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 9 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 AASUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ONO 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10101 CURRENT LOCAL AGENCY ILITY FAC10# APPROVED BY NAME PHONE#WITH AREA CODE lel lD � 00 F MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIEL A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY