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STATE OF CALIFORNV' WATER RESOURCES CONTRO' BOARD FORM 'B': UNDEMROUND STORAGE TANK PRO .,�AM (azCOMPLETE TANK TANK PERMIT APPLICATION INFORMATION CA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E; B TANK REMOVED Oq N FACILITY/SITE NAME WHERE TANK IS INSTALLED: I Pa L j C- Lod I FARM TANK-YES❑ NO a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP CIFY 00 A. OWNERS TANK ID# amnL B. MANUFACTURED BY: r C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O � 11. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE HU& ❑ 2 PETROLEUM B. C. [:] 1 UNLEADED ❑ 2 LEADED Rj DIESEL F-13 CHEMICAL PRODUCT F-14 OIL RODUCT ❑ 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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A TYPE OF ❑ 1 DOUBLEWALEED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 810A METHANOL COMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E;;-BStlRKNONFj ❑ 99 OTHER F71 RUBBER LINED ❑2 ALKYD LINING F--] 3 EPDXY LINING F-] 4 PHENOLIC LINING C. INTERIOR F-] 5 GLASS LINING ❑ 6 UNLINED 95 LINING ❑ 15 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO :�R D. CORROSION ❑ 1 POLVETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑3 VINY E:] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 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 NKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED-FRENCH A U 91 NON A U NKNOWN 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 A0 O CRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 #OWN 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURETESTING P S 91 NONE UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) STIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION k AGENCY M FACILITY ID# TANK ID# = = 01 il= 10 10 1 D CURRENT LOCAL AGENCY FACILITY IDN APPROVEDB NAME PHONE M WITH AREA CODE OlLt31 1 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT# BY: w FORM B(6-29-66) THIS FORM MUST BE ACCOMPANI D BY A FACILITY/SITE APPLICATION, FORM IN,UNLESS AMAHRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY