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STATE OF CALIFORNO WATER RESOURCES CONTR�OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _- Z :6 MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E]6 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: / FARM TANK-YES❑ NO W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# / B. MANUFACTURED BY: Cn C. YEAR INSTALLED ID. TANK CAPACITY IN GALLONS: 00 I II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. - UNLEADED El 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑ BO EMPTY 0 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 8 C.A.S.# C.A.S.#: 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 SINGL WALLED 4 SECONDARY CONTAINMENT 99 OTHER TEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-� 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B 100%MEFHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 P NOLIC LINING LINING F--] 5 GLASS LINING 6 UNLINED 5 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER D.CORROSION ❑ 1 PO YETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION HODICPROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A CUJ2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED AU 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELU 95 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. ©S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ml o ? a 10 161010111 CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY A PHONE#WITH AREA CODE PERMIT NUMB PERMIT APPROVAL DAW PERMIT PIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE OT. FEE CODE RECEIPT# BY: FORM B S 29-68) THIS FORM MUST BE ACCOMWNIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLtsS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY