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STATE OF CALIFORN• WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PE MANENTLY CLOSE D'Te NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: a� FARM TANK-YES O •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN R MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O II. TANK C NTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IP A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 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 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER N E OF HAZARDOUS SUBSTANCE STORED&C.A. N C.A.S.N: III. TANK CONSTRUCTION MARK O E ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑ SINGLE WALL"WITH ERFERIORLINER ❑ 95 UNKNOWN SYSTEM ❑251NGLE WALLID ❑4 CONDARYCONTAINVIENT ❑99 OTHER ❑ 1 STEELIIRON ❑NASPH SS STEEL ❑3 FIBERGLASS ❑4 STEELCLAO W/RBERGLASS REINFORCED PLASTIC B'NATERUL ❑5 CONCRETE ❑ POLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ ZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBEA LINED ❑ NI ❑ 3 EPDXY LINING ❑4 PHENOLIC UNI NG LINING ❑5 GLASS UNING ❑ ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITFHAN ? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEFHLENE WRAP ❑ ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLSS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 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 WALLE A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i 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 CLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S F SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE LLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN ACE i.EBTIMATEO DATE LAST USED(MO/Vfll 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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#Q-`-F--' JURISDICTION � AGENCY# FACILITY IDN l TQANK ID k F7PERMIT ID* APPRO±FEEE� PHONE N WITH AREA CODE NUMB PERMIT APPROVAL DATERE IR�OON DATE AMOUNT URCHARGE AMT. EIPTR BY: FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY