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STATE OF CALIFORNIA WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM - W= TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE �.B?NK REMOVED � ) FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co CD A. OWNERS TANK ID# o B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E�KMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OILPRODUCT ❑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.# C.A.S.#: ELS III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OFDOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM f 2 ❑SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER Ol'STEEUIRON ❑ 26'TAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CIADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F75 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP ❑ ❑ ❑ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR I RUBBER LINE ❑ 2ALKYD LINING F-]3EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING [;;J6'(NLINED ❑ 95 UNKNOW/N,, /n ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO C -9WOTHER 4�4�'�•` D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2RORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 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 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 FIBERGLASSPIPE A U 91 NONE C. MATERIALA 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U a 100%METHANOL COMPATIBLE FRP U GALVANIZEDSTEEL 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. N ,JY P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS W'_ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA E LAST USED(MO/YR) 2.ESTIMA D QUANTITY OF 3.W S TANK FILLED WITH SU8 T EREMAININGIN R ATERIAL?M ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT, APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# aRl = I d CUP ENT LOCAL AGENCY FACILITY ID# APPROVED YNA E - E#W REA CODE c.- , I 3 C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY; FORM B(6-29-aa) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AaMRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY