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STATE OF CALIFORNIA; WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TANK PRO TAN TANK PERMIT APPLICATION INFORMATION s COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. R} z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [EJ,5'CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT L] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C) C. YEAR INSTALLED r D. TANK CAPACITY IN GALLONS: jr Lam( IL 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 2 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE 7 METHANOL ❑ 99 OTHER(DESCRIBE JN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.q h/ C.A.S.M III. TANK CONSTRUCTION MARK ONE PTEM ONLY IN BOX A,B,C,&D A.TYPE OF OUBLE WALLED F-1 3 SINGLE WALLED WITH EKTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON F-]2 STAINLESS STEEL F-] 3 FIBERGLASS f-]4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYL CHLORIDE F--] 7 ALUMINUM ❑8 1 O METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] i RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LININGS ❑ 5 GLASS LINING e 6 UNLINED ❑ 95 UNKNOWN, E] IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑ YES [:] NO 99 OTHER D. CORROSION ❑ i POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V€NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDPKOUND,BOTH IF APPLICABLE A.SYSTEM TYPE A(U2 SUCTION A U 2 PRESSURE Aly GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELlIRON 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 ;�) 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 95 UNKNOWN A U 99 OTHER . 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 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Pif�e PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 3 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA LAST USED(MO/YR) 2. ESTIM ED QUANTITY OF 3.WA TANK FILLED WITH S B E REMAINING IN ATERIAL? YES ❑ NO GALLONS VIA THIS FORfO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE, IS TPUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# �TANK ID# 6 (.� CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAIIAE ' PHONE#WITH AREA CODE 1A I( PERMIT NUMBER PERMIT APPROVAL DATE PERMIft EXPIRATIOPI DATE J CHECK# PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPT# BY: J - FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI-ET BY A FACILITYISITE APPLICATION, FO R M 'A',UNLESWRRENT FORM'A' HAS BEEN FILED vv DATA PROCESSING COPY