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STATE OF CALIFORNI6b WATER RESOURCES CONTRO§OARD FORM `B': UNDE ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z CO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [:] 7 PE MANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED 0 IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO .♦� I"► 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY. C.YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: 11. TANK C_ONTENTS 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 ❑ 2 LEADED 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,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBIEWALLED ❑ 3 SINGLE WALLED WITH EK01OR LINER ❑ 95 UNKNOWN SYSTEM E5111GLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER EUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 YVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 0%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE NIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 MIBBERUNED [:]2 ALKYO LINING F-13 EPDXY UNING ❑4 PHENOLIC LINING C.INTERIOR 5 GLASS UNING I-I�,.�,,,ED ❑95 UNKNOWN LINING ❑ �'"'""� ❑ ISUNING MATERIAL COMPATIBLE WITH ID096METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHIENE WRAP 2 TAR OR ASPHALT ❑ 3 VIWLWRAP ❑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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER ASTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%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 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P 8 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 THISFORM 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 C-O�U ANTTYY,# JURISDICTION# II AGENCY# FACILITY ID# TANK ID# �1..1�LJ L�LJ e* CURRENT LOCAL AGENCY F/ACI ID# APPR NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT# BY: / FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIE7P AFACILITY/SITE APPLICATION, FORM 'A',UNLESS AC,.HRENT FORMA' HASBEENFILED ' DATA PROCESSING COPY