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STATE OF CALIFORNI16 WATER RESOURCES CONTRCOOARD " FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY1 PERMIT F-13 RENEWALPERMIT HANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK ONE ITEM TERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED ,� N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (}� 0 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# I B. MANUFACTURED BY: C.YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. r A. ❑ i MOTOR VEHICLE FUEL ❑ 2 P LEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 P UCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS [:] 5 HAZARDOUS [:] BO EMPTY ❑95 UNKNOWN Er2 WASTE ❑7 METHANOL ffpr6THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.G.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EKTERIOR LINER ❑95 UNKNOWN SYSTEM SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Eal(STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1D0%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXYUNING ❑4 PHENOL KING C. LINININTERIOR ❑5 GLASS LINING ❑6 UNLINED UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100°6 METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 AGRAVITY 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL U 5 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. OVI. P S 1 VISUALCHECK �S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 5 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWNP S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST ISS DLM R) 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. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m� o CURRENT LOCAL AGENCY FACILITY ID)# / APPROVED BY NAME PHONE N WITH AREA CODE P 7J PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRA N DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIE'mmmmom nY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY