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STATE OF CALIFORIO WATER RESOURCES CONTIe'BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �` P TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN2 INFORMATION FOR EACH TANK. ry MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: �" • �( 6 FARM TANK•YES FkrNO ❑ N 1a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9 2 N A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLEDuk D. 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. El UNLEADED 1:12 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT [:] 4 OIL - F-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY95 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.# CA&#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ W OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 UMINUM ❑ 8106%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 P NOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ (SEINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT n 3 7L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE Ej ff55 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 AUJ 5 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_A5 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 Ay.�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 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 5 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LU l L v CURRENT LOCAL AGENV FACILI]Y IpM APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [C�K PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: / s \u1 VVV FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A',UNLESS A CURRENT FORM'A' HAS BEEN(FIL ED DATA PROCESSING COPY