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STATE OF CALIFORNIA* WATER RESOURCES CONTROLMARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m�" TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED T NK I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE FRKNKREMOVED 0 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I tn I..► 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# B. MANUFACTURED BY: 0) C.YEAR INSTALLED 5 1D. 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 P ROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 P ODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ct Sf� Q C.A.S.#: U s HAZARDOUS SUBSTANCE STORED 8 C.A.S.# W 5-f le TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLEWALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑W OTHER ❑ 1 STESUIRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 ALVANIZEDSTEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 A LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C.INTENIOR LINING ❑5 GLASS LINING ❑6 UNUN ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%M NOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHA ❑ 3 VINYLWRAP ❑ 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFAROVFrpniimp\lkj 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 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLE 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR S ONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAC 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES EF] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION 4 AGENCY# FACILITY ID# TANK ID# 131:� , 3 o 0 ZP"IMITNUMBER AGEN Y F CILI ID# APPROVED BY NAME / /") PHONE#WITH AREA CODE PERMIT APPROVAL DATE P MIT EXPIRATION DATE PERMIT AMOUNTSURCHARGE AMT. FEECODE RECEIPT BY; Ask FORM B(6.29-B8) THIS FORM MUST BE ACCOMPANIEDWA A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A dMENT FORMA' HAS BEEN FILED DATA PROCESSING COPY