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STATE OF CALIFORNIA WATER RESOURCES CONTR*OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM A TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK. IO MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 2 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT // '' ��.❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C/ C/. L(/o (/ yNLPn FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C) A. OWNERS TANK ID R B. MANUFACTURED BY: C.YEAR INSTALLED 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. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1PRODUCT ❑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 HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.W III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBEGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F] 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL I ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑3 VINYLWAAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 9/ NONE P 8 95 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? [-]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. f APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY F JURISDICTION M AGENCY P FACILITY ID M TANK ID N = = = i CURRENTLOCALAOENCY FACILITY101 APPROVED YNA E PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE' PERMIT EKPI TION DATE CHECK# TAMOUNT • SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED OAT"k PROCESSING COPY