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STATE OF CALIFORNIA WATER RESOURCES CONTR(_30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATIONPERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z ozs (,�, FARM TANK-YES NO ❑ N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-S SPECIFY W A. OWNERS TANK ID# V B. MANUFACTURED BY: OD C. YEAR INSTALLED �� D. TANK CAPACITY IN GALLONS: C d II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A Eflll MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED E] 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �1 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) U IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#:��J III. TANK CONSTRUCTION MARK ONE ITEM NLY IN BOX A,B,C,&D A TYPE OF BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑/SECONDARYCONTAINMENT ❑99 OTHER STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 L CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK 1 STEE MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM E]81 N%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR E:11 RUBBER LINED ❑2 UKYO LINING F-]3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO LC2'�99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE `S5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE Ata UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE 4 V95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL 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(9 5 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. �)O P 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS /A_/ P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 1 NONE P S 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIM ED DATE LAST USED(MO/YR) 2. EST)PATED QUANTITY OF 3.WA TANK FILLED WITH ylTAGALLONS NCE REMAINING IN ATERIAL? [—]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# I d6 I FFFI F 6o lo CURRENT LOCAL AGENCY FACILITY ID p 47E E PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAMITEXPIRATIO DA CHECK# PERMITAMOUNT SURCHARGE AMT. RECEIPTS BY: FORM e(6 29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 4 UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY