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STATE OF CALIFORN* WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PRRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z I� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [:] 7 RMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TA ,NK REMOVED 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: III 5 3z V E /20 r< a tj FARM TANK-YES NO ❑ (L) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 II. TANKCONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A Ml MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL F--] 3 CHEMICAL PRODUCT F--] 4 OILy 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 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL El 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING F--] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS 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 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 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER J 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [a] = 65 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME G '/ PHONE#WITH AREA CODE of / Gb PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE y 4 �q CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: J 0i FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED _,(/�.•