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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PRORAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 'ERMANENTLY CLOSEDraa 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED Q% FACILITY/SITE NAME WHERE TANK IS INSTALLED: / FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY uj A. OWNERS TANK ID# _ B. MANUFACTURED BY: lI A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4c� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 ffTROUEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT Fe 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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&C.A.S.# &c C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑ 1 D BLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ED STEEL CLAD W/RBERGLASS 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 F-11 RUBBERLINED ❑2 ALKYD LINING 3 EPDXY LINING 0 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED � 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIRE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYEIHLENEWRAP EP-2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 F18ERGLASS 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 ACU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 5 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 5 ALUMINUM ;65= A U 7 STEEL CLADW/FRP A U B 1 OD%METHANOL COMPATIBLE FRP U9 GALVANIZED STEEL 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS Ntiv Q P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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# 16- 1 Q l m�' EEI CURRENT LOCAL ENCFALITY ID#/ APPROVED By NAME PHONE#WITH AREA CODE 113 8 rw PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY; FORM B(fi-29-BB) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY