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STATE OF OALI FO RN I WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "'oz r€7 MARK ONLY 011"NEW PERMIT Q 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS K ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YESE:n NO -Oh- N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID#,91 PD�ETANK UFACTUR�IN C. YEAR INSTALLED CAPACILLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 01 MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL 0 3 CHEMICAL PRODUCT ❑ 4 OIL L2111"PRODUCT 1:1 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS E] 80 EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DFSCRIBE 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,A D A TYPE OF ❑�DOUBLE WALLED [—] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLEWALLED F-�4 SECONDARY CONTAINMENT 99 OTHER Pri STEEL/IRON F-1 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD MFIBERGLASS REINFORCED PLASTIC B.TANK F-�5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 108%METHANCLCOMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER I RUBBER LINED ��2 ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING LINING C. INTERIOR F—] 5 GLASS LINING E56 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-] 2 TAR OR ASPHALT F--] 3 VINYL WRAP "[:] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 0 91 NONE L095 UNKNOWN E] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 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 STEELARON 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 A6 CONCRETE A U 7 STEELCLAD WIFRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE: P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VOUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEI DATE LAST USED(MO/YR) 2. ESTIMATED OU `T'IITY OF 3.WAS ANK FILLED WITH SUBSTAN MryRING IN -GALLONS ATERIAL? YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P 11 11 AND TD THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT: APPLICANT'S NAME{PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L I �o I bt F /1 CURRENT LOAI*AGENCY FACILITY ID 8 APPROVED BY �Ij PHONE It WITH AREA CODE PERMIT NUMBER PERMIT APP Y PER EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY. FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM,X,UNLESS RENT FORM`A` HAS BEEN FILED DATA PROCESSING COPY