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STATE OF CALIFOR WATER RESOURCES CONTIlb BOARD FORM 'B': UN RGROUND STORAGE TANK PR GRAM i bm TANKTANK PERMIT APPLICATION INFORMATION ANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T i0 ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCL 2 INTERIM PERMIT RMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK RE ONE ITEM El ❑ 4 AMENDED PEMOVED MARK ONLY / S W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO I fV fV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK IDa e2l B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: 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 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 ,7 / HAZARDOUS SUBSTANCE STORED 8' C.A.S.q C.A.S.a, G✓ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ,�P SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD WIFIBERGtASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYDLINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 101A METHANOL? ❑YES ❑ NO EF990THER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIFA! VE 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 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A ;j` CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A N h5 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. P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TE STING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI TED DATE LAST USED IMO/YR) 2. ESTIMA ED QUANTITY OF 3. AS TANK FILLED WITH NC / SU S REMAINING IN N n GALLONS N TT MATERIAL? ❑YES ❑ NO ✓�'1'/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY M FACILITY ID# TANK ID# 3 ` 1a lo I / � I I) I oe) I o CURRENT LOCAL AGENCY FACILITY ID# APPROVEDBY NAE PHONE#WITH AREA CODE vAIX PERMIT NUMBER PERMIT APPROVAL DATE ERMIT E PIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE lAm RECEIPTk BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPARIEDWA FACILITY/SITE APPLICATION, FORM'A',UNLESS A RENT FORMA HAS BEEN FILED DATA PROCESSING COPY