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STATE OF CALIFORNIt WATER RESOURCES CONTROF _ ��/ /�/Q I3 FORM `B': UNDERGROUND STORAGE TANK PRO adAAM lvl TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAN . MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� FARM TANK-YES❑ NO'w Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Im A. OWNERS TANK ID P O ,.'r -2 I Z, B. MANUFACTURED BY: Id.N K C. YEAR INSTALLED +'' D. TANK CAPyCITY IN GALLONS: �111f 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),13NOTMARKED,COMPLETE ITEM D. A1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. [—] 1 UNLEADED E]2 LEADED � DIESEL 15 B.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(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.R C.A.S.R: .Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 BNGLE WALLED WITH EXTEROR UNER ❑95 UNKNOWN SYSTEM isri SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM MATERIAL _]8100%METHANOL COMPATIBLE FRP E]9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ID2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED ;'FUNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%MEMWOL7 ❑YES ❑ NO ❑990THER D. CORROSION ❑I POLYETHIENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE ;P<9S UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE & SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(-R)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A/U U�6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 10M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Alp 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR I3 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P B 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE- P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION P AGENCY k FACILITY ID P TANK ID 4 EHI I oo (o 19 CURR T LOCAL AGENCY FACILITY ID F APP V AME I PHONE n WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT 1 SURCHARGE AMT. FEE CODE RECEIPTM BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIESdY A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA HAS BEEN FILED