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STATE OF CALIFORNIS WATER RESOURCES CONTR OARD FORM B': UNDERGROUND STORAGE TANK PRORAM V TANK TANK PERMIT APPLICATION INFORMATION Y `° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION 0 7 PE MANENTLY CLOSED TANK ONE ITEM E] 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE EZTANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: N FARM TANK-YES NO js I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# � } B. MANUFACTURED BY: j� N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.7),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A, ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL 0 3 CHEMICAL PRODUCT �4 OIL DJPRODUCT D 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS E] 5 HAZARDOUS 0 80 EMPTY E]95 UNKNOWN 2 WASTE 7 METHANOLOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF Cy HAZARDOUS SUBSTANCE STORED 8 C A.S.# �� CAS #' / III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM FQSINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER Eg-lSTEEUIRON 2 STAINLESS STEEL Ej 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL Ej 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL D 95 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBER LINED El 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PEE LIC LINING LINING ❑ 5 GLASS LINING E]6 UNLINED 5 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 102 0 METHANOL? 0 YES E] NO E:] 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 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 A6 U4 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 A SINGLEWALLED 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP • GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTIONSYSTEMCIRCLE 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 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P $ 1 NONE P S 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 D 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOC AGENCY FACILITY ID#� APpRO%EO BY N`AA('MM/`E�f'y PHONE#WITH AREA CODE PERMIT NU BER PERMITAPPROVALDATEI) 3 PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: \ FORM B(6-29-00) THIS FORM MUST BE ACCOMPANIED A FACILITYMITE APPLICATION, FORM 'A',UNLESS A C ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY