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STATE OF CALIFORfo WATER RESOURCES CONT BOARD «; FORM 'B': UNDERGROUND STORAGE TANK PROGRAM = TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. . , MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED tc) FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID N `a. B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: 3 D s W II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 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,BEL(q� D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A/ HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: / xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D A. TYPE OF ❑ I AUED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑ 2 STAINLESS SFEEL ❑3RBERGLASS ❑4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑2 ALKY INING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING F-15 GLASS LINING LINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 160%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 1KNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER rUl OA B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 C. MATERIAL A U 5ALUMINUM AU CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 00#- P8 1 VISUAL CHECK P 8 2 INVENTORY flECONCILIATION 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U D(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]GALLONS E] NO THIS FORM HAS B EN 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 X JURISDICTION N AGENCY N FACILITY ID N TANK ID X QZI D 10 1 a v C) 16 CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE PS / RR�B �� 8 L � PERMITNUMBER PERMIT APPROV T PERMI EXPIRATION A CHECKN PERMfT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTX BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIE AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HASBEENFILED � DATA PROCESSING COPY