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STATE OF CALIFORN 1 WATER RESOURCES CONTF BOARD FORM B': LINDD RGROUND STORAGE TANK PRSGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.y MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LJ a CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 0� FACILITY/SITE NAME WHERE TANK IS INSTALLED: ClIm ." / FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 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 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL E71 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 ,,I HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: /M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOK A. B, C. & D A TYPE OF ❑ I DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER [-] 95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING F]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING E06 UNLINED C. MATERIAL ❑ 95 KNOWN 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH IDAMETHANOL? ❑ YES ❑ NO 990111E1 D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3. WAS TANK ED WITH A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER `\`pv^JIIII B. CONSTRUCTION A( U Jl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I FEE CODE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE( PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A L/L�,6 CONCRETE A U ] STEELCLADW/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/ U J95 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. S P VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTIN P 8 ]PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER � GI VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY F 3. WAS TANK ED WITH SUBSTANCE REM IN INERT L� Ej YES [_]NO FACILITY ID# GALLONS CURRENT LOCAL AGENCY FACILITY ID# THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJU4Y, AND TO THE BEST OF MY KNOWLED(k,, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY 1/ N EIA // fo z `\`pv^JIIII PERMIT NUMBER PER ITAP VAL DATE Z WIERMITEXPIRATION DATE CHECK# PERMIT AMOUNT SURCI I FEE CODE RECEIPT# 4RECT. TANK ID # vo HONE # WITH AREA CODE BY: FORM B (6-29-881 THIS FORM MUST BE ACCOMPANI6w.,/ A FACILITY/SITE APPLICATION, FORM 'A', UNLESS 090RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY V