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STATE OF CALIFORNI* WATER RESOURCES CONTROL FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: D O / FARM TANK-YES❑ NO F..A. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C, YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL F-11 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 C.A.S.W HAZARDOUS SUBSTANCE STORED&C A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLEDWITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM E]2 SINGLE WALLED 4 SECONDARYCONTAINMENT ❑99 OTHER ❑ 1 STEELIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ?STEEL CLADWIFlBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 1 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNED ❑2 A D LINING ❑ 3 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNbNED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10096METHANOL? ❑YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR HALT F-13VINYL WRAP ❑4 RBERGIASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE \ ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 A U 95 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL 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 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,OP{ S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAROSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 41 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED N PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTI OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINI G 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# I Ll 10 1l - [4-0 60 CUR RE T LOCAL AGENCY FACILITY ID# APPROVED BY AM PHONE k WITH AREA CODE RAI n 1 PERMIT APPROVAL DATE PER TEXPIRA ION DATE PERMIT NUMBER ICHECK a PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �J FORMSS-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ACJRRENT FORMA' HASBEENFILED DATA PROCESSING COPY