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STATE OF CALIFORNF WATER RESOURCES CONTRf BOARD FORM 'B': UND9RGROUND STORAGE TANK PRO%RAM TANK TANK PERMIT APPLICATION INFORMATION :mom COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT „ 1 O ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ,L;4 PANK REMOVEDDO o9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOSPECIFY N A. OWNERS TANK ID p C,S 1 B, MANUFACTURED BY: a N C. YEAR INSTALLED IrA D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I/_4 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL Ll S JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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&Gk&If C.AS.If III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER �95 UNKNOWN ❑ SYSTEM 2 SINGLE WALLED F-]4 SECONDARY CONTAINMB 99 OTHER [5§1 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED ®15 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO [g99 OTHER I'l I'LL D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ED91 NONE 6Z19-1 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U . 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(UDD5 UNKNOWN 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 S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A05 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 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES 0N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY M FACILITY ID B TANK ID M = -7hl 101010111 CURRENT LOCAL AGENCY iAGIL O APPROVED BY NAME_ S � PHONE N WITH AREA CODE PERMIT NUMBERr^, PERMIT APPROVAL DATE ��+ (PERMMI�ITT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SRE APPLICATION, FORM 'A',UN'LESSA*eKRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY