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STATE OF CALIFOFWA WATER RESOURCES COVOL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF MATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ER<&ANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1 O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED o FACILITY/SITE NAME WHERE TANK IS INSTALLED: / cn 7 7 FARM TANK-YES EI 10 ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTI A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: ODO 11. TANK CONTENTS 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.PRODUCTID C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-1 3 CHEMICAL ION GAS [-] 5 HAZARDOUS 80CT J 80 EMPTY 95 UNKNOWN [j2 WASTE ❑7 METHANOL ❑99OTHER(DESCRIBEET FUEL ❑IN TEM DTBELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# LL Jr-- C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SIDLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 190%METHANOL COMPATIBLE FRP ' MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E�WUNKNOWN ❑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 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A f 95 UNK OWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U A U7 STEEL CLAD W/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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S ONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P 5 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 I INERT MATERIAL? L]YES [_-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# TANK ID# 3 0 © o CURRENT NCY FACILITY IDN APPROVED PHONE#WITH AREA CODE PERMIT NUMBER -_" PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: /�� FORM B(6-29-fie) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COP,