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STATE OF CALIFORN16 WATER RESOURCES CONTRIWOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. _ z 10 MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM F—] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ) IS FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4 dzl� FARM TANK-YES❑ NO (� Fa 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ) (� A. OWNERS TA NK ID# y' B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. 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 ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,A D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOLCOMPATIBLE FRP MATERIAL � ❑9 BRONZE ❑ 10 GALVANIZED STEEL ff�95'UNKNOWN ❑99 OTHER C. INTERIOR .,- F-11 RUBBER LINED ❑2 ALKYD LINING F—]3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑6 UNLINED 5 UNKN N ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO THE &loe D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI NY RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A&JS 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 5 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 A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAD ELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P S I PRESSURE TESTING 1 NON P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTL LOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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# a� 10a o a CURRENT I CALo AGENCYc�EFACT TY ID# APPROVED NAM PHONE#WITH AREA CODE � i� a / PERMIT NUMBER PERMIT APPROVAL DATE YtRMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHAR AMT. FEE CODE RECEIPT# BY: Is ORM B 88) THIS FORM MUST BE AC PANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UALESS A CURRENT 'A' HAS BEEN FILED DATA PROCESSING COPY of