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STATE OF CALIFORNIA WATER RESOURCES CONTROI -OARD ` FORM `B': UNDERGROUND STORAGE TANK PROGRAM �l COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EADNK. TANK TANK PERMIT APPLICATION INFORMATION MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 714 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURER TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1® A. OWNERS TANK ID 16 B. MANUFACTURED BY: U C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. `•� ji A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT F-14 OIL ❑� 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS V E ❑5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 1CA2 WASTE ❑7 METHANOL K99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# �j) wZ._ C.A.S.#: 3 Z .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM X 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELARON 2 STAINLESS STEEL F-1 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 'I33 6 PDLYVINVL CHLORIDE �7 ALUMINUM E]8 lffi%METHANOLCOMPATIBLEFRP MATERIAL J ' ❑ 9 BRONZE E] 10 GALVANIZED STEEL F]95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RLJBBERU14ED ❑ 2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED 1&95 UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 100%MMMOL? YES E] NO 99 OTHER 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 INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A43)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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A'V 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 IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �L. SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? l&fhES [] No T THIS FORM AS 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY F2ACILITY IDN AP VAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7 sa) THIS FORM MUST BE ACCOMPANIES.Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A ZGRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY