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STATE OF CALIFORK,i WATER RESOURCES CONTIG, BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �" TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -_� Z 10 MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT —]5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CL NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: D FARM TANK-YES NO tV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-YSO SPECIFY W A. OWNERS TANK IDk I R. MANUFACTURED BY: N C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: d QO 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 �RRODUCT ❑4 GASAHOL ❑ 5 JET FUEL [D 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.# iyA C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER _ STEEL/I9ON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ MATERIAL B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING E]4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �NUNED ❑ 95,UNKNOWN ❑ IS UNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES .❑NO OTHER ✓ 4A/12- D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Er5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C. MATERIAL A U 6ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP - A U 9 GALVANIZED STEEL A U 5 UNKNOWN' A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 6 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK B 21NVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4ELECTRONICMONITOR P 3 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 ] PRESSURE TEBTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATI LAST USED(MO/YR) 2. ESTIMATED OU TIN OF 3.WAS TAN FLLE WITH BUBSTANC NGIN GALLONS ' `INE r IAL? E)WITH ❑ NO THIS FORM AS 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# CURRENT LOCAL AGENCY FACILITY ID# APPR E V NAME PHONE#WITR AREA CODE a ) z-5 PERMIT NUMBER PERMITAPPROV DATE PERMPIRATIO DA Z3TE CHECK# PERMIT AMOUNT SURCHARGE AAIT. EE CODE RRCEIPT# BY: ft� i i FORM B(6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A BENT FORMA' HAS BEEN FILED nATA DROCESSING COPY