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STATE OF CALIFORNIA* WATER RESOURCESCONTROlfARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-12INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ffgg TANK REMOVED a Cl FACILITY/SITE NAME WHERE T' NK IS INSTALLED: G FARM TANK-YES NO Ph I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 01) A. OWNERS TANK ID# B. MANUFACTURED BY: (y�✓� �� C. YEAR INSTALLED C� D. TANK CAPACITY IN GALLONS'. G o II. TANK CCjNfENTS 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 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS F-� 80 EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,f CAS.M HAZARDOUS SUBSTANCE STORED&C.A.S.# V III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED F-�4 SECONDARY CONTAINMENT [:] 99 OTHER 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F7 6 POLYVINYLCHLORIDE F--] 7 ALU E] 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE F-] 10 GALVANIZED STEEL 5 UNKNOWN 0 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING F-1 3 EPDXY LINING 04 PHEN INING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES [:] NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VIM' P 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION []91 NONE Ltf5 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 A U 5 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 5 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 (CONCRETE A U 7 STEEL CLAD W/FRP A U B 1W%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(T1 5 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. L P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLB P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 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 USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ',Il) SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES D 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# �AGENY## 1 FACILITY ID# TANK ID# a- CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYN E PHONE#WITH AREA CODE U 1� 113 PERMIT IN MBER PERMIT APPROVAL DATE ER IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: FORM B(6-29-813) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESS A ,RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY