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STATE OF CALIFORNI40 WATER RESOURCES CONTROSPARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOW] G INFORMATION FOR EACH TANK. H MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 O ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED :2- FACILITY/SITE FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- N $O SPECIFY co A. OWNERS TANK ID# 2B. MANUFACTURED BY: -Al. C. YEAR INSTALLED N D. TANK CAPACITY INGALLDNS: ,CAU IL TANK ONTENTS 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 �� !EE ADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ q OIL I PRODUCT FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑2 WASTE THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D FA. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH DRERIOR LINER ❑95 UNKNOWN TEM ❑ 2 SINGLE WALLED ❑q SECONDARY CONTAINMENT ❑99 OTHERK ❑ 1 STEEL/IRON 257AINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEFHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ ❑ ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. srsrEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAM TY 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE I PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U fi CONCRETE A U ] STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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. ESTIMATED DATE LAST USED(MO/VR) Z ESTIMATED OUANTIIY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH 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 F OUT�NTY# JURISDICTION# AGENCY# FACILITY ID# -y---1 �m TANKID# 2 ZNT LOCAL AGENCY FACILITY ID# APPROVED BYNAME PNONE#WITN AREA CODE N MBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE WW' 1 CNECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: Fy FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED it FORM FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FI F u DATA PROCESSING COPY \