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STATE OF CALIFORNIP WATER RESOURCES CONTRO" 10ARD FORM 'B': UNDffGROUND STORAGE TANK PROWkAM ` TANK TANK PERMIT APPLICATION INFORMATION �^ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE -��NK REMOVED Ing (V FACILITY/SITE NAME WHERE TANK IS INSTALLED: L r FARM TANK-YES❑.NO 41h. , I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �" 3 CD A. OWNERS TANKID# B. MANUFACTUREDBY: C71 C. YEAR INSTALLED i A kk� D. TANK CAPACITY IN GALLONS: '550 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A._pf 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED -J -Z EADED ❑ 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,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.AS.# CA S X'. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINERNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM E] 6100%METHANOL COMPATIBLE FRP MATERIAL El BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENO CLINING LINING ❑ 5 GLASS LINING E] 6 UNLINED 95 UNKNOWN .A L ❑ IS LINING MATERIAL COMPATIBLEWITH 100%MEIHANOL9 YES E] NO,OTHER U,N.L- D.CORROSION ❑ i POLYETHLENEWRAP ❑2 TAOORASPHALT ❑ 3 VINYLWRAP r-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION E]91 NONE .ti 5 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 AII 5 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 25 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U� OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P H I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WEUS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S I PRESSURE TESTING P S 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? E] 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 B JURISDICTION R AGENCY B FACILITY ID p TANK ID k CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE N WITH AREA CODE 0VF RH I 0 I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIO4 DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANKS BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS>.SIRRENT FORM'W HAS BEEN FILED t DATA PROCESSING COPY