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STATE OF CALIFORNI* WATER RESOURCES CONTROOARD FORM `B': UNDERGROUND STORAGE TANK PROAM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � '" ,Z' I l7 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQSEQ TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED0/ l FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Cn F-L I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY / N A. OWNERS TANK ID# B. MANUFACTURED BY: 00 C. YEAR INSTALLED M 6, D. TANK CAPACITY IN GALLONS: XO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 5�3'�lMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �-PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCf IBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# Azle, C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U�2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED El2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING � LINING ❑ 5 GLASS LINING CJS UNLINED ❑ 95 UNKNOWN ,(/� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO E g OTHER 441A v D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE [ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION AU 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A(N CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI ATDATE LAST USED(MO/YR) 2. ESTIMATED QUANT' OF 3, WAS TA K FILLED WITH SUBSTANCE R GIN INE T ERIAL? ❑YES ❑ NO GALLONS TAI'S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY E JURISDICTION# AGENCY# FACILITY ID# TANK ID# I :1 66 0 fAGENCY FACILITY ID# APPROVED BYPHONE#WITH AREA CODE PERMIT APPROV L D TPERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE AC70MPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A Mul"T FORM'A' HAs DIGrR'T.ED DATA PROCESSING COPY